INCOME/EXPENDITURE STATEMENT

PLEASE COMPLETE BOTH SIDES OF THIS FORM

Name: / Account No:
Address: / Tele No:
E-Mail Address: / Amount Outstanding / £
STAGE 1 / INCOME / STAGE 2 / EXPENSES
Week/Fort/
Month / Week/Fort/
Month
Wages/Salary (self) / Mortgage
Wages/Salary (partner) / Mortgage Endowment Policy
Income Support / Second Mortgage/Secured Loan
Jobseekers Allowance / Rent
Working Tax Credit / Council Tax
Child Tax Credit / Water Rates
Child Benefit / Gas
Incapacity Benefit / Electricity
Sickness Benefit / Telephone (incl mobile)
Pension Credits / Ground Rent/Service Charges
Works/Private Pension / Building/Contents Insurance
Maintenance Received / Life Insurance/Pension
Non Dependant Contributions / Housekeeping
Other1 / Clothing
2 / School Meals/Meals at Work
TOTAL INCOME / Alcohol/Cigarettes
TV Rental/Licence
Cable/Satellite TV
Magistrates Court Fines

STAGE 3

/ Week/Fort/ / County Court Judgements
Month / Maintenance Paid
TOTAL INCOME (Stage 1) / Car Tax/Insurance/MOT/Petrol
Less / Public Transport
TOTAL EXPENSES (Stage 2) / Laundry
Prescriptions
EXCESS INCOME
/ Childminding
Hire Purchase Agreements
Bank Loans
Credit Cards
SAVINGSSelf / Catalogue
Partner / Other1
2
TOTAL
/ TOTAL EXPENSES

PAYMENT OFFER: - £______PER WEEK/FORT/MONTH COMMENCING ______

Date form issued: / To be returned by:

To

Daventry District Council Revenues and Benefits Service, Lodge Road, Daventry, Northampton NN11 4FP

RSD105 Rev 002PLEASE COMPLETE THE FOLLOWING IN BLOCK CAPITALS

PERSONAL DETAILS / SELF / PARTNER
Date of Birth
National Insurance Number
Number & Ages of Children
Disabled
Serious Illness/Long Term Sick
Recent Family Bereavement
One Parent Family
Recent Relationship Breakdown
EMPLOYMENT DETAILS / SELF / PARTNER
Employer’s Name
Employer’s Address
Employer’s Head Office
(if different from above)
Works Payroll Reference
Job Title/Occupation
Full or Part Time
Self Employed (Yes/No)
PAY AND INCOME / SELF / PARTNER
Your Usual Gross Pay / Wk/Mth / Wk/Mth
Your Normal Net Take Home Pay / Wk/Mth / Wk/Mth
Give Details Of Other Deductions (if applicable)
Existing Attachment of Earnings
Court Orders
INCOME SUPPORT/JOBSEEKERS ALLOWANCE CLAIMANTS
Name of Claimant
Claimant’s Date of Birth
Claimant’s National Insurance Number
How Much IS/JSA Do You/They Receive
Address Of Benefits Office Responsible For Paying Your IS/JSA
Other Benefits Received
Amount Received

You can save yourself incurring further substantial costs by agreeing to make weekly, fortnightly or monthly payments direct to the Council. Contact the Authority immediately on telephone number 01327 302293 or

e-mail .

IMPORTANT

Failure to supply this information is a criminal offence and a fine of up to £100 can be imposed.

Supplying false information will lead to a fine of up to £500.

DECLARATION

I declare that the information given within this form is a true and accurate assessment as to my financial circumstances and is provided to the best of my knowledge. I confirm that should any changes occur, I will notify Daventry District Council immediately.

SIGNATURE:______DATE:______