Council Tax and Housing Benefit arrears repayment means test
Complete the means test form so North Somerset Council can establish your ability to pay your outstanding arrears.
You are required to pay your outstanding balance within six months. If you are unable to pay the balance within six months, please provide a detailed statement confirming why you want the council to consider a longer repayment plan. Please include evidence to support your statement (e.g. evidence of your income, evidence of any additional arrears, confirmation of any current benefit entitlement etc). We will be unable to consider a longer repayment plan without a statement and supporting evidence.
Please complete and return the means-test form, together with your statement and supporting evidence (if applicable), within 10 days of the letter to avoid possible further recovery action.
Section 1: Person one
Title:
Name:
Marital status:
Date of birth:
National insurance number:
Address:
Postcode:
Telephone number:
Dependants
Names and ages of any children:
Any other dependants (give details):
Employment
Name and address of employer:
Payroll:
Telephone number:
Income
State amount and whether per week, month or year
Net take home pay £ per
Overtime/commission/bonuses £ per
Self employed income £ per
Tax credits £ per
Income support £ per
Other state benefits £ per
Contribution from children £ per
Maintenance received £ per
Other income (please specify) £ per
Section 2: Person two (if applicable)
Title:
Name:
Marital status:
Date of birth:
National insurance number:
Address (if different):
Postcode:
Telephone number:
Dependants
Names and ages of any children:
Any other dependants (give details):
Employment
Name and address of employer:
Payroll:
Telephone number:
Income
State amount and whether per week, month or year
Net take home pay £ per
Overtime/commission/bonuses £ per
Self employed income £ per
Tax credits £ per
Income support £ per
Other state benefits £ per
Contribution from children £ per
Maintenance received £ per
Other income (please specify) £ per
Section 3: expenses
State amount and whether per week, month or year
Housing/utilities
Rent/mortgage £ per
Council tax (if paying) £ per
Water £ per
Gas £ per
Electricity £ per
Other household fuels £ per
Building/contents insurance £ per
Life assurance £ per
Telephone (including mobile) £ per
TV/satellite/internet £ per
Appliance rental (please specify) £ per
Fines, county court judgements £ per
Repairs/maintenance
Repairs £ per
Household maintenance £ per
Window cleaning £ per
Other (please specify) £ per
Motoring
Insurance £ per
Road tax £ per
Spares/servicing/MOT £ per
Breakdown cover £ per
Fuel and parking £ per
Fares and travel £ per
Housekeeping
Food £ per
Toiletries/cleaning £ per
Clothing/footwear £ per
Laundry/dry cleaning £ per
Children
Childcare £ per
School fees £ per
School meals £ per
Pocket money £ per
School trips/activities £ per
Health
Dentist/prescriptions/opticians £ per
Health insurance £ per
Other (please specify) £ per
Pets
Pet food £ per
Vet bills/pet insurance £ per
Personal and leisure
Newspapers/magazines £ per
Sports/hobbies £ per
Socialising (pubs/outings) £ per
Alcohol £ per
Cigarettes/tobacco £ per
Hairdressing/haircuts £ per
Church/charity £ per
Other (please specify) £ per
Priority debts
Rent/mortgage
Amount owed £
Repayment offer £ per
Agreed with creditor yes no
Secured loans
Amount owed £
Repayment offer £ per
Agreed with creditor yes no
Court fines
Amount owed £
Repayment offer £ per
Agreed with creditor yes no
Maintenance/child support
Amount owed £
Repayment offer £ per
Agreed with creditor yes no
Utilities
Amount owed £
Repayment offer £ per
Agreed with creditor yes no
HM Revenues & Customs
Amount owed £
Repayment offer £ per
Agreed with creditor yes no
Other (please specify)
Amount owed £
Repayment offer £ per
Agreed with creditor yes no
Repayment
How much do you propose you pay to repay your balance?
£ per
If you are unable to pay the balance within six months, please provide a detailed statement confirming why you want the council to consider a longer repayment plan:
Declaration
I declare that the answers given are true.
Sign:
Date: