Is This Your Only/Principle Home (Please Circle) Yes No

Income & Expenditure Form

Leasehold Property Address:

Is this your only/principle home (please circle) Yes No

Income Monthly

Income Support/ JSA £ ESA/ Incapacity Benefit/ Severe Disability Allowance £ Working Tax Credit £ Child Tax Credit £ Wages £ Child Benefit/ Child Maintenance £ Pension/DWP £ DLA/ PIP £ Attendance Allowance/ Carer’s Allowance £ Universal Credit £ Contributions by someone else living in the household £ Rent from let properties £ Interest earned from Savings £ Income earned from Stocks and Shares £ Other Income £ Total £

Assets

Properties owned other than this Lease Address:

East Kent Housing Income & Expenditure Form July 2015 2

Property size: Market Value: £ Mortgage: £ Address: Property size: Market Value: £ Mortgage: £

Address: Property size: Market Value: £ Mortgage: £

If additional properties owned, please provide details on a separate sheet.

Investments

Savings Stocks and Shares £

Expenditure Monthly

Mortgage £ Mortgage Lenders Name: Address:

Council Tax £ Electricity £ Water /Sewerage Rates £ Gas £ Food/ household products and toiletries £ Internet/telephone/Sky £ Mobile Phone £ Petrol/ Diesel £ Vehicle expenses (MOT & Road Tax) £ Car Insurance £ Clothes £ Insurance (home/life) £ Childcare costs Inc. clubs £

Leisure £ £ £ Total £

Debts Monthly

Who you owe the debt to Total debt Arrangement to pay back debt Mortgage Arrears £ £ Court Fines £ £ Utility Arrears £ £ Loan £ £ Loan £ £ Loan £ £ Catalogue £ £ Credit Card £ £ Credit Card £ £ Store Card £ £ Other £ £ Total £ £

Total Income

Total Expenditure

Monthly repayment proposal

Notes:

 The information I have given on this form is correct and complete as far as I know and believe.  I understand that if I knowingly give information or evidence that is incorrect, incomplete or false, I may be liable to prosecution or other action.  By signing this declaration you are giving your consent for us to approach other organisations to share information and to authorise them to disclose this to us in order to help assess your financial situation.

Signature:______Date______

East Kent Housing Income & Expenditure Form July 2015