Income & Expenditure

Please provide the following important information to allow us to help you and return the completed form via email. Please complete all the boxes unless it is not applicable to you.

Name

Date of birth

Email address

Address

Our reference number

Mobile telephone number

Landline telephone number

National Insurance Number

Name of Bank

Household Details

Number of Adults

Number of Children Under 16

Number of Children Aged 16-18

Employment Details

Are you employed?

Employers Name & Address

Net wages (after tax/NI etc.)

Salary frequency

Payroll Reference

Income

Total Wages

Pension

Universal Credit

Employment Support Allowance

Pension Credits

DLA/Personal Independence Payment

Carers Allowance

Attendance Allowance

Child Benefit

Tax Credits

Maternity pay

Other

Total (Average Per Month)

Expenditure

Mortgage or rent

Council tax

Gas

Electricity

Water

Food/housekeeping

Home insurance (buildings/contents)

Life insurance

TV licence

Home telephone / broadband

Mobile telephone

Public transport travel

Car finance (if applicable)

Car expenses - fuel

Car expenses - road tax

Car Insurance

School meals/costs

Childcare / School wraparound care

Secured loans

Unsecured loans

Credit cards

Other living costs

Total (Average Per Month)

Breakdown

Total Income

Total Outgoing

Amount Leftover

Offer of Payment

Notes

Ross & Roberts Limited

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