Derogation application form Licensee detailsName of licensee* Email* Address 1* Address 2* Address 3 Town/city* Postcode* Date* DD slash MM slash YYYY Details of derogation requestReference to code document* Reference to WRC section* Reference to sub section* Version number* Link to document* What type of derogation are you applying for? A specific derogation from the WRC as it applies to one or more Wholesale Contracts A general derogation from the Stapling Condition A specific derogation from the Stapling Condition If you are applying for a general derogation from the Stapling Condition please provide details below of any other supporting parties. As a minimum supporting parties’ contact details should be provided.*Area 1: Are you applying for a derogation as a specific derogation under the stapling condition of the WRC (applicable to you as an entry singularly) or for a general derogation under the stapling condition (applicable across all Integrated Appointees).*You should include details of why you consider the derogation is specific or general.Area 2: Description and supporting rationale as to why non-compliance would be expected to occur without the requested derogation*You should include details of any pre-emptive action or mitigation measure you have taken and what further action you are proposing to take to ensure compliance is restored as soon as is reasonably possible.Area 3: A comprehensive assessment of the impact of the non-compliance*As outlined in section four of the guidance on the assessment and consultation of a derogation request, we will consider and so companies should include information on the range of items we outlined, which include the impact of the proposed derogation on: • Customers • Competition and level playing field • Resilience • Better regulation • Central systems and operations • Other affected partiesArea 4: Proposed period of the derogation*A derogation will be granted for a defined period and may contain triggers to remove the derogation in certain circumstances. Please outline the period of the derogation you are requesting. In addition, as outlined in section 3 of the guidance, please provide assurance that there are no additional measures or reasonable options that could be taken (time and cost to mitigate the non-compliance, thus eliminating or minimising the requirement for a derogation.Area 5: Schedule 8 of the MACIf the applicant is seeking a derogation which impacts on schedule 8 of the MAC the effect should be outlined below.Area 6: Any relevant additional information to support your requestIncluding, in the case of a general derogation application, supporting information from other market participants.Area 7: Contracted partiesPlease provide details of all parties to s66D/117E Agreements who will be affected by the proposed derogation. Ofwat will engage with these parties as part of its derogations assessment process.Supporting evidence Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, jpg, jpeg, png, gif, Max. file size: 32 MB, Max. files: 5. If you have any files or documents to support your derogation request please upload them here. You can upload up to five files.NameThis field is for validation purposes and should be left unchanged.