A Claim Form For Housing Benefit And Council Tax Support Page 27

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Employer’s certificate of earnings
tear-off 3
Slough Borough Council, Benefit Service, P.O Box 1032, Slough, Berkshire SL1 3YT
Employer’s certificate of earnings
PRIVATE & CONFIDENTIAL
PART 1
To be completed by employee
1. Your name
2. Occupation
3. Address
4. Signature
PART 2
(To be completed by employer) Slough Borough Council would be grateful if you will assist your employee
by completing sections 5 to 22 of this certificate and return it to the address at the top of this certificate.
5. Date employment
6. Date of last pay rise
7. Date next pay rise due
started
8. National
9. Works No.
10. Tax Code
Insurance No.
11. Please tick if you get paid:
Weekly
Fortnightly
4 Weekly
Calendar monthly
12. Other (please specify)
13. Please indicate the method of payment e.g. cash, cheque, direct into bank account
14. Normal basic wage
Normal hours worked
Regular Overtime
Yes
No
15.Please enter the details of your employee’s pay for the last 5 weeks, 3 fortnights or 2 monthly pay periods (including overtime,
bonus, commission, tips, SSP, SMP etc)
National Insurance
Occupational or
Tax paid
Pay
No. of
Gross
Gross
Working
Contributions paid by
personal pension
by employee
Period
hours
Pay for
pay
Tax
employee
contributions
ending
worked
pay period
to date
Credit
This Pay
This Pay
This Pay
Year
Year
Year
Period
Period
Period
to date
to date
to date
If Statutory Sick Pay or Statutory Maternity Pay is included in the gross pay please indicate clearly which and how much
16. Name
17. Date
18. Business Name
19. Telephone No
20. Business Address
21. Company’s Official Stamp
DECLARATION
I confirm that the information provided is true and complete and I understand that I may be prosecuted
•
if I state something which I know to be false or do not believe to be true.
22. Signature of employer

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