Benefits Check Form

Benefit Check Form

Your Details

Title
MrMrsMissMs

First name

Surname

Your email

DOB

Your Partners Details (if applicable)

Title
MrMrsMiss

First name

Surname

Email

DOB

Please provide details about your children (if applicable)

Do all the people listed above live with you?
YesNo

If no, please give details

Do any other people not listed above live at your address? If yes, please detail each person, state how old they are and if they are either (1) in receipt of benefits (which type) or (2) working (how many hours pw and gross weekly wage)

Do you have a mortgage? If yes, how much do you owe?

Do you rent? If yes, how much is your full rent per week?

Any rent free weeks?
YesNo

If you rent, then please state whether you rent from a private or local authority/housing association:

Post Code:

Number of bedrooms:

Council tax band:

& liability:£ pw/pm/pa

How many hours per week do you work?

What was your GROSS income for the last tax year?

What is your expected income for the current year?

Date started current employment:

Are there any gaps in employment for you or your partner in the last two years; if yes, state what these are below:

Have you got any savings? If yes, state how much in total:£

List below all your income:wages, pensions (State or Occupational), benefits (e.g. JSA/ESA/Tax Credits/DLA/PIP/AA/Child Benefit/Housing Benefit/Council Tax Reduction etc), maintenance, or anything else. Please state whether monthly or weekly:

List below all your partners income:wages, pensions (State or Occupational), benefits (e.g. JSA/ESA/Tax Credits/DLA/PIP/AA/Child Benefit/Housing Benefit/Council Tax Reduction etc), maintenance, or anything else. Please state whether monthly or weekly:

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