Information About Income and Capital

Ullensaker Tax Office Side 1 av 4 Information about income and capital

Personal data Name Personal ID number Marital status

Address Work Home phone Mobile phone phone

Employer

Name of spouse/cohabitant Spouse/cohabitant’s personal ID number

Number of children you provide for Do(es) the child(ren) live with you more than 50% of the time? 0-5 yrs 6-10 yrs 11-17 yrs Yes No

Income per month Type of income Own Spouse/cohabitant Enclosure no Gross income - Tax withholding Total net income + Child benefit + Cash benefit + Child maintenance + Children’s income + Other income Total income

Fixed expenses per month Housing expenses per month Amount Enclosure no Rent/service charges Interest and instalments on housing loans Local government taxes Total housing expenses

Visiting address Phone 66 10 80 00 Org. no 990 488 789 Rådhuset Furusethgata 12 JESSHEIM Fax 66 10 80 01 Bank account 6345 06 02355 [email protected] IBAN NO12 6345 0602 355 www.ullensaker.kommune.no BIC NDEANOKK

Other fixed expenses per month Amount Enclosure no Child maintenance Fines collected by the Norwegian National Collection Agency Child day care centre/before/after school supervision Total other expenses

Total housing expenses and other fixed expenses per month

Property that you own, wholly or partially Address Land Title Ground Unit Ownership number number lease number interest no

Address Housing cooperative’s Unit Ownership org. no number interest

Bank deposits, securities and shares Bank or business manager Account Account no Balance type

Other assets (e.g. motor vehicle, boat etc.) Description Registration no Presumed value Debt/encumbran ces

Ullensaker Tax Office Side 3 av 4 Other information that may have a bearing on the case:

All information provided in the form must be documented by enclosures.

I/we understand and accept that the case officer may check all information given and contact the employer, if relevant.

Place Date

Name (signature) Spouse/cohabitant (signature)