Payment Plan Review

Income & Expenditure Form

To prepare for your payment plan review, we kindly ask you to complete the Income & Expenditure form below with as much information as possible. Once we receive the completed form, we will contact you to arrange your review.

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Name *

Address *

Address Line 1

City

State / Province / Region

Member No. *

Email *

Phone *

Income

When completing the income form all figures should be monthly amounts.

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Earned Income (After Tax & NI)

Statutory Sick Pay

JSA (Contribution)

ESA

Child Benefit

Carers Allowance

PIP / DLA Mobility

Pension Credit

Private Pension

Partner's Private Pension

Industrial Injuries Benefit

Partner's Income (After Tax & NI)

Working Tax Credit

JSA (Income Based)

Income Support

Child Tax Credit

PIP / DLA Care

Maternity Allowance

State Pension

Partner's State Pension

Attendance Allowance

Other

Expenditure

When completing the expenditure all figures should be monthly amounts.

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Net Rent (Including Arrears)

Water Rates (Including Arrears)

Electricity (Including Arrears)

Clothing/Maintenance

Childcare Costs

TV License

Internet

Car Finance/Insurance

Catalogues

Fines

Credit Union (Current Payment)

Council Tax (Including Arrears)

Gas (Including Arrears)

Housekeeping (Food)

School Meals

Travel Expenses

Mobile/Landline

Sky/Digital/Cable

Loans/Credit/Store Cards

Medical Costs

Other

Payment Plan Review

Income & Expenditure Form

Income

Expenditure

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