Adopters MT Form

Means Test of Income and Expenditure

Part A: Family IncomeMonthly Amount

1: Pay / You / Partner
Pay (after deductions for tax, national insurance and pension only) including regular overtime e.g. 1/12th of annual bonus
Drawings if self-employed
2: Benefits and pensions (paid directly to parents) / You / Partner
Employer’s sick pay (after compulsory deductions)
Incapacity Benefit
Statutory Maternity/ Paternity/ Adoption Pay/ Maternity Allowance
Bereavement Benefit
Working tax Credit (paid separately from wages and excluding any Childcare Element paid)
All pension payments being received
Other benefits
3: Benefits (paid to household for family/children) / Household
Jobseeker’s Allowance/ Employment and Support Allowance
Child Tax Credit
Child benefit forother childrenin the household
(NOTincluding those named on the first page - Review of Adoption Financial Support Adoption Form 17)
4: Other sources of income / Household
Net interest only from savings, capital or investments
Income from boarders/lodgers
Income from unfurnished properties
Income from furnished properties
Maintenance payments received for any child in the household
Existing Adoption/Special Guardianship allowances only (including any enhancements or specific payments for special needs) paid for any child
5: Income relating to the child/children being adopted / Household
Any regular interest on capital and/or income to which the child/children has/have a legal interest and entitlement, e.g. trust fund, property or other type of legacy. Do NOT include payments from Criminal Injuries Compensation Awards or Government Child Trust Fund
Any other income

Please turn over

Part B: Family ExpenditureMonthly Amount

1: Home / Household
Mortgage payments, Life/ Medical/ Home/ Buildings Insurance
Rent (minus housing benefit if applicable)
Council Tax (minus council tax benefit if applicable)
2: Other outgoings / Household
Regular payments for essential housing improvements, vehicle upgrade or consolidation loans (i.e. undertaken specifically to facilitate the placement of the child/ children)
Maintenance payments for children not part of the household
Court orders
Private pension contributions
National insurance contributions if self-employed
Reasonable childcare costs for other children in the household
(NOT including those named on the first page - Review of Adoption Financial Support Adoption Form 17),e.g. nursery fees including school dinners for full days or before
and after-school clubs (do NOT include childcare payments made by HMRC as the childcare element of working tax credits)

Please remember to attach evidence for each figure you put under ‘Monthly Amount’ in Part A and Part B of the Means Test.

Adopters/ Parents signature:

Date:

Current address:…………………………………………………………………………..

…………………………………………………………………………..