Self Employed Earner – Certificate of earnings

If you receive a wage or hourly rate from a company you are classed as employed and do not need to complete this form.

If you have only just started your business and have not been trading for very long then you can use an estimate for what you think your income and expenditure will be / has been for the first 13 weeks of your trading. After 13 weeks we will contact you to review your Housing Benefit claim.

Section 1: About you

Name / National Insurance Number
Address: (home)
Post Code / Telephone number
Email address

Section 2: About your business

Business name
Business address
Please describe the nature of your business
Are you a self-employed child minder? / Yes / No / OFSTED registration number
When did you start your business? / DD/MM/YY
When did your current financial year start? / DD/MM/YY
How many hours per week do you work in your business?
Is your business a partnership? / Yes / No / What share of the profit / loss is yours?
Is your husband/wife/civil partner also a partner of this business? / Yes / No / What is their share of the profit?
Do you have prepared accounts (audited or not) for the last financial year? / Yes / No
Are they a reflection of your current income? / Yes / No
If not a reflection of your current income, please say why they are not below:
If you have a set of accounts for the last financial year and these reflect your current earnings, please go to Section 5 of this form and send us a copy of the accounts
If you don’t have any accounts, you have not been trading for more than 13 weeks or your trading circumstances have recently changed go to Section 3 using your best estimate where applicable

Section 3:Income & Expenditure

These figures should show your total sales BEFORE any expenses are deducted
The figures below are for the period / DD/MM/YY / to / DD/MM/YY
Total Sales/Takings/Income / £
plus Payments or grants received to set up your business / + £
minus Cost of purchases / - £
Total Income (Gross profit) / £

Section 4:Expenses

These are the costs for the period of time show in Section 3. You must only include amounts which relate solely to the business e.g. telephone – if calls are made, you must apportion the total cost in accordance with the amount of private use and enter the amount for business use only
Business only
Rent (business premises/proportion of home rent for business) / £
Mortgage interest / £
Business Rates / £
Water rates / £
Heating and Lighting / £
Cleaning / £
Telephone / £
Business Insurance (inc. Public Liability insurance) / £
Property Insurance / £
Bank charges / £
Interest payments on any business loans / £
Repair / Replacement of business assets (excluding motoring) / £
-Was this covered by insurance? / Yes / No
Leasing charges / £
Motoring expenses
Fuel / £
Lease / £
Insurance / £
Road Tax / £
Repairs / £
Other expenses
Accountant’s charges / £
Advertising / £
Printing / Stationery / Postage / £
Bank charges / £
Drawings of cash/goods belonging to business for own use / £
Wages paid to self / £
Wages paid to marital partner / £
Wages paid to others / Name / £
Address
Wages paid to others / Name / £
Address
Wages paid to others / Name / £
Address
Other (please state) / £
Other (please state) / £
Other (please state) / £
National insurance / £ / Per week
Pension contributions (paid to private pension scheme) / £ / Per week
Income / PAYE Tax / £ / Per year
Are your trading figures for the next 6 months likely to be similar to those given? / Yes / No
If no, please explain why they may be different below:
Please supply proof of the income and expenses entered.

Section 5: What to do next.

Completed forms can be returned:

•By using our online Customer Contact Form

•By email to

•By post to Wakefield Council Revenues and Benefits Service, Wakefield One, PO Box 700, Burton Street, Wakefield WF1 2EB. Please ensure you attach the correct postage.Please note that we do not advise sending valuable documents through the post. If you need to enclose any additional sheets, please put your name at the top of each additional page.

•In person at Wakefield One Customer Access Point, Burton Street, Wakefield

Section 6:Declaration

This information is in support of my claim for Housing/Council Tax Support

•I declare that the information given on this form is true and complete to the best of my knowledge.

•I will inform the Revenues and Benefits Department immediately should my/our income or circumstances change.

•I understand that failure to declare a change in circumstances is a criminal offence and I may be prosecuted (Theft Act 1968 or Social Security Acts or Fraud Act 2006).

•I understand that a delay in telling you of any change in circumstances may mean that I have to repay any benefit which has been overpaid.

Name: (please print)
Signature: / Date: