Financial Statement
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1Financial Statement
Name:
Date:
Address:
Number of people in household:
*weekly/monthly
A. Income
Wages/salary
£ __________
D. Priority Debts
Wages/salary (partner)
£ __________
amount owed
*weekly/monthly
Working Tax Credit
£ __________
Mortgage arrears
£ ___________ £ __________
Child Tax Credit
£ __________
Secured loan
arrears
£ ___________ £ __________
Jobseeker’s Allowance
£ __________
Ground rent &
Income Support
£ __________
Service charge
Child Benefit
£ __________
arrears
£ ___________ £ __________
Other state benefits
£ __________
Rent arrears
£ ___________ £ __________
Non-dependant(s) contributions
£ __________
Council Tax
Other income _________________ £ __________
arrears
£ ___________ £ __________
Gas arrears
£ ___________ £ __________
Total income
£ __________
Electricity arrears
£ ___________ £ __________
*weekly/monthly
B. Expenditure
Magistrates’
Mortgage
£ __________
Court Fine
£ ___________ £ __________
Second mortgage/secured loan
£ __________
Income Tax
£ ___________ £ __________
Mortgage endowment policy
£ __________
Maintenance
arrears
£ ___________ £ __________
Ground rent/service charges
£ __________
Rent
£ __________
Other
£ ___________ £ __________
Council Tax
£ __________
£ ___________ £ __________
Building/contents insurance
£ __________
Total payments
to priority debts
£ __________
Life insurance
£ __________
Gas
£ __________
E. Money available
Electricity
£ __________
for Credit Debts
£ __________
Water Rates
£ __________
F. Credit Debts
Food and household items
£ __________
amount owed
monthly offer
of repayment
Childminding
£ __________
_______________
£ ___________ £ __________
TV Costs
£ __________
_______________
£ ___________ £ __________
Maintenance/child support
£ __________
_______________
£ ___________ £ __________
Travelling expenses
£ __________
_______________
£ ___________ £ __________
School meals/meals at work
£ __________
_______________
£ ___________ £ __________
Clothing
£ __________
_______________
£ ___________ £ __________
Telephone
£ __________
Other ________________________ £ __________
_______________
£ ___________ £ __________
_______________
£ ___________ £ __________
Total expenses
£ __________
_______________
£ ___________ £ __________
C. Money available
£ ___________ £ __________
for creditors
£ __________
Total owed
£ ___________
*
delete as appropriate. Remember to keep to weekly
Total monthly payments
£ __________
or monthly amounts. Do not mix the two.
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