Low income tariff application form


How to complete this form

  1. Complete the online form below (Please complete all mandatory fields and upload any supporting evidence)

  2. We will try to give you a decision within 10 working days. We will contact you if we need any more information.

  3. If your application is not successful we will tell you why.


Do you need help completing this form

Call us on: 0345 357 2401 Metered or 0345 357 2402 Non Metered (open Mon - Fri 8am - 6pm, Sat 8am - 2pm)

email: advancecareteam@affinitywater.co.uk



We can provide this information in large print or different formats, if you need it. Please contact us for details.

If you would like to set up a password, or have a medical need that could be impacted by a loss of supply, complete our Priority Services registration form and we will do everything we can to help.

Fields marked with * are mandatory.

  • 1Your Details

Who is the person named on the water bill?

Title *
First name *
Last name *
Address *
Post code *
Daytime phone number
Evening or mobile number
e-mail address
Customer number *

National Insurance details

Please give the name and National Insurance number of the person who receives one or more of the benefits or tax credits.

Full name *
National Insurance number *Please enter your NI number so we can process your application


The information I have given is correct to the best of my knowledge and I understand that if I provide any information which is false, you may refuse to consider my claim.

If my circumstances change and it may affect my claim, I will tell you straight away.

I give permission for the Authority who gives me benefit or tax credit to give you any information to confirm the information I have provided.

Warning If you deliberately give us misleading information you are committing a criminal offence and could be prosecuted.


My household meets the conditions for help under the Low Income Tariff *
I have read the above statement and confirm that the information I have provided is true

Supporting documents

Please upload a copy of the latest 'notice of entitlement' for benefit. This must be in the same name as the water account holder and should also show their address. Without the supporting documents your application can not be processed.

Please note: You may add a second document but the total files uploaded should not be larger than 3mb. 

Upload document *
To upload a document, click on 'Browse' then find the document on your computer and double click or choose 'Open'.
Additional document upload, if required.

How did you find out about the Low Income Tariff?

Please select
If you selected other please provide details

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