Statement of Income and Expenditure Form

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Statement of Income and Expenditure Form Powered By Docstoc
					                                                                                                                             Revenues Services
                                                                                                                             Test Valley Borough Council
                                                                                                                             Beech Hurst
                                                                                                                             Weyhill Road, Andover
                                                                                                                             Hants. SP10 3AJ

                                                                                                                             Telephone: (01264) 368500



                               STATEMENT OF INCOME/EXPENDITURE
                                                                             (Internet Version)


 Name and Address                                                                                                 Date




                                                                                                                  Account Reference number if known




You have been asked to complete this form to give the Council a fuller picture of your circumstances. If you do
not wish to answer any question please state your reason. It should be noted that a refusal to give information
requested may mean the Council will not accept your offer.

Do you work ? YES / NO
Are you employed/self employed ? ................................................................ please state which
What is your income ? £ ............................................ per week/ per fortnight/ monthly/ other (please state)
Name and address of your employer ................................................................................................................
...........................................................................................................................................................................
........................................................................................................... Payroll Reference ................................
Does your spouse/partner work ? YES / NO
If YES please give details of employer .............................................................................................................
...........................................................................................................................................................................
........................................................................................................... Payroll Reference ................................
What is their income ? £ ............................................ per week/ per fortnight/ monthly/ other (please state)
Do you receive any State Benefits/ Family Credit ? YES / NO
What type and amount of benefit do you receive ? ..........................................................................................
£ .................................................................................. per week/ per fortnight/ monthly/ other (please state)
How much private pension do you receive ? £ .......................... per week/ per fortnight/ monthly/ other (please
state)
How much do you receive for maintenance / child support payments ? ........................................
Do you support any other people in your household ? YES / NO
          Adults .................................. Children ............................... Please state ages ..................................
Do you receive money for board and lodging from anyone within your household and if so how much ?
          £ ......................................... per week/ per fortnight/ monthly/ other (please state).

         PLEASE TURN OVER TO TELL THE COUNCIL ABOUT YOUR HOUSEHOLD EXPENDITURE
                                                HOUSEHOLD EXPENDITURE
                  Please state AMOUNT and FREQUENCY of payment e.g. weekly, monthly etc.

                                                     £             frequency                                                                         £           frequency

 Rent/Mortgage                                                                         TV Licence

 Food                                                                                  TV Rental/Cable

 Council Tax                                                                           Lottery/Scratch cards

 Gas                                                                                   Catalogue - how much is outstanding

 Electric                                                                                    £ ………………

 Other Fuel - please state                                                             Cigarettes

                                                                                       Newspapers/Magazines

 Water                                                                                 Alcohol

 Telephone                                                                             Loans -

 Household Insurance                                                                         what for ……………..

 Life Insurance                                                                              how much is outstanding ?

 Pension Plan                                                                                £………..

 Car -                                                                                 Other payments to Test Valley

      Road Fund Licence                                                                      Housing Benefit Overpayment

      Insurance                                                                              Community Charge/Poll Tax

      Petrol                                                                                 Rent Arrears

 Bus Fares                                                                             Other payments

 Travel to Work / School                                                               - please state who to and what for




Do you have any outstanding fines/compensation to pay YES/NO
How much do you owe ? £ ........................ How much do you pay each week ? £ ...............................
To which Court ? ..........................................................



                                                                DECLARATION

         I declare that the information provided on this form is true and accurate to the best of my knowledge
         and belief.
             I wish to repay the debt at £ .................................. each week / fortnight / month

             I enclose my first payment of £ ................................


         Signature:          .............................................................................   Date: .................................................

         Name in block capitals: ..............................................................              Tel No: .............................................

				
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posted:8/19/2011
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Description: Statement of Income and Expenditure Form document sample