Directorate of Resources,
City Hall, Beaumont Fee,
Lincoln. LN1 1DB
Telephone: (01522) 873355
Facsimile: (01522) 521736
Website: www.lincoln.gov.uk
Certificate of Earned Income
To be completed by the employee
Name: Pin:
Address:
Employee/Works No: National Insurance No.
Occupation:
Signature:
This form must be completed by your employer and any falsification of a wage could lead to
prosecution. Your assessment will normally be based on these figures and any increase or
decrease in earnings should be notified to the Housing and Council Tax Benefits office immediately.
To be completed by the Employer
I would be grateful if you could assist your employee by confirming the details above, providing the details
requested below and returning it to the address at the top of this form.
Please indicate how often the employee is paid. If ‘other ‘ applies please give the period.
Weekly Fortnightly 4 Weekly Calendar Monthly Other
Please indicate the method of payment e.g. cash, cheque, direct into bank account
Normal basic wage £ Normal hours worked
Gross pay for the last 5 weekly, 3 fortnightly or 2 monthly/4 weekly periods (including overtime, bonus, SSP, SMP etc). If
the amounts are unrepresentative of your employee’s expected earnings in the future, please put an explanatory note on
the back.
Date commenced work if after 1st April:
Date from which any future increases are to be paid:
Wk Pay No. of Gross pay Gross Tax paid by National Occupational Tax
No. period hours Wkly/ pay to employee Insurance Pension or Credits
ending worked Mthly date Contributions Personal
Wkly/ Year to Wkly/ Year contributions
Mthly date Mthly to date Wkly/Mthly
If Statutory Sick Pay or Maternity Pay is included in the gross pay please indicate clearly which and how much
Name and address of employer I confirm that the information given is true and complete
(Rubber stamp should be used) Telephone Number:
Signed by (or on behalf of) the employer:
Date: