<p> Ullensaker Tax Office Side 1 av 4 Information about income and capital</p><p>Personal data Name Personal ID number Marital status</p><p>Address Work Home phone Mobile phone phone</p><p>Employer</p><p>Name of spouse/cohabitant Spouse/cohabitant’s personal ID number</p><p>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 </p><p>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 </p><p>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 </p><p>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</p><p>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 </p><p>Total housing expenses and other fixed expenses per month</p><p>Property that you own, wholly or partially Address Land Title Ground Unit Ownership number number lease number interest no</p><p>Address Housing cooperative’s Unit Ownership org. no number interest</p><p>Bank deposits, securities and shares Bank or business manager Account Account no Balance type</p><p>Other assets (e.g. motor vehicle, boat etc.) Description Registration no Presumed value Debt/encumbran ces</p><p>Ullensaker Tax Office Side 3 av 4 Other information that may have a bearing on the case:</p><p>All information provided in the form must be documented by enclosures.</p><p>I/we understand and accept that the case officer may check all information given and contact the employer, if relevant.</p><p>Place Date </p><p>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</p><p>Name (signature) Spouse/cohabitant (signature) </p>