Discretionary Housing Payment Application Form Page 5
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6About your income and outgoings – all claimants must answer this section
20)
Please give details of all money coming in to your household. You must state the amount you receive
.
as well as the type of income
.
Weekly income
You
Your Partner
Net earnings from employment
£
£
Income Support or Job Seekers Allowance
£
£
Working Tax Credit or Child Tax Credit
£
£
Housing Benefit
£
£
£
£
Child Benefit
£
£
Pension Credit, State Pension or Works Pension
Any other state benefit
£
£
Money received from parents or friends
£
£
Any other income – please give source
£
£
£
£
Weekly expenses
Weekly
Arrears if any
Please change any monthly expenses to weekly figures
payments
Rent
£
£
£
£
Mortgage
Council Tax
£
£
Electricity
£
£
Gas
£
£
Water rates
£
£
£
£
TV licence and rental
Telephone
£
£
Food
£
£
Household products
£
£
Clothing
£
£
£
£
Car or public transport
£
£
Maintenance
Fines- court orders
£
£
social fund
Balance owing
Weekly repayments
Loans and other credit debts–
eg
loan
Assistance
/
, Catalogues, credit/store cards etc.
Name of lender
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Please provide proof of these outgoings (ie. Letter from DWP, Last Catalogue Statement, Letter from Court) Failure to
provide proof will delay your application.
...........
Claim ref:
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Parent category: Business