Benefits Check Form

Advice by Email - Citizens Advice Lancashire West

Please fill in as much information below as possible, the more information we receive, the better advice we can give. Fields marked with an ‘*’ are required.

PLEASE NOTE: Benefits Check by Email from Lancashire West Citizens Advice is only available to residents or people working in our catchment area (see Local Information). For visitors living in another part of the UK, please visit Find Your Nearest Citizens Advice Office.

Please complete our Benefits Check Form

Benefit Check Form

Your Details

Title

First name

Surname

Your email

DOB

Your Partners Details (if applicable)

Title

First name

Surname

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?

You	Your Partner (if applicable)

What was your GROSS income for the last tax year?

You	Your Partner (if applicable)

What is your expected income for the current year?

You	Your Partner (if applicable)

Date started current employment:

You	Your Partner (if applicable)

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:

By sending this email, I confirm that my client has given their permission for their information to be passed on to Citizens Advice Lancashire West for the purpose of helping them with the problem detailed. I understand that this information will be kept confidential to Citizens Advice. Click here for our full data protection policy

I confirm the above *

A copy of your request for advice will be automatically emailed to you for your records.

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Name	DOB	Full Time Education?	Disabled?	Child care Costs £ (weekly)
		YesNo	YesNo
		YesNo	YesNo
		YesNo	YesNo
		YesNo	YesNo