Please complete and return to the Corporate Collections section by uploading to the overpayments document form. Email to or send by post to the address below.

Please note

As everybody has different income and expenditure, the ones listed are those which are found to be the most common. Should you have any which are additional (income and/or outgoings) to these, please provide details in the space provided.

Breakdown of Income and Expenditure

Name: Claim/Reference Number:

Address:

Date: Home Telephone No:

Mobile Telephone No:

Email address:

Name of employer:______

Address of employer: ______

______

Employers telephone number:______

Head Office Address:______

______

______

Works no / pay reference:______

Type of Income / Amount
State if
Weekly or monthly / Comments
Earnings (inc self employed)
Partners earnings
Benefit received from DWP (e.g. Job Seekers Allowance, Disability Living Allowance)
State Retirement Pension
Partner’s State Retirement Pension
Private Pension
Partner's Private Pension
Income from additional adults residing in the property
(e.g. children over the age of 18)
Maintenance / Child Support
Child Benefit
Tax Credits
(not included in your earnings)
Any other income (please provide details)
TOTAL
Type of Expense / Amount
State if
Weekly or monthly / Comments / For Office Use Only
Housing
Rent
Mortgage
Service Charge(s)
Water
Council Tax
Gas
Electricity
Other household fuels (please state)
Household Services
Buildings Insurance
Contents Insurance
Life Insurance
Telephone (landline)
Telephone (mobile)
Internet
TV Licence
Repairs, Service contracts
Appliance rentals
Child Support paid by you
Fines, CCJ’s etc
Child Care Costs
Private Pension contributions
Medical/Accident Insurance
Motoring/Travel
Vehicle finance
Spare/Servicing
Road Tax
Insurance
Breakdown cover
Fuel
Parking
Fares/Travel
Type of Expense / Amount
State if
Weekly or monthly / Comments / For Office Use Only
Food/Housekeeping
Food, Toiletries, Cleaning
School Meals/Meals at work
Pets (food & insurance)
Tobacco
Clothing & footwear
Misc. Goods & Services
School trips/Activities
Hairdressing
Professional/Union fees
Laundry/Dry cleaning
Medicines/Prescriptions
Dentist
Opticians
Personal/Leisure
Newspapers, Magazines
Sports, Hobbies,
Entertainment
Children’s pocket money
Church/Charity
Sundries/Emergencies
Self Employed
Income Tax
National Insurance Contributions
VAT
Other Costs
Type of Expense / Amount
State if
Weekly or monthly / Comments / For Office Use Only
Other Debt Repayments
Rent arrears
Mortgage arrears
Council Tax arrears
Credit/Store Card 1
Credit/Store Card 2
Credit/Store Card 3
Loan 1
Loan 2
Loan 3
TOTAL / Total Income used
Total Expenses used
Excess Income available

Please provide details of what you feel to be a realisticproposal for repayment. Although this may not be what is agreed, it will be taken into consideration when looking at your case.

Amount: £…………….

Frequency of payment e.g. monthly/weekly …………………

Date you can make your first repayment by ..….……………

Most convenient date for payments to be made (e.g. 1st of each month, every Friday)

………………………………………………………………

To make the agreed repayments you will automatically be provided with a Standing Order mandate to complete and forward to your own bank/building society. If you prefer to make repayments by payment vouchers, please state below.

I would prefer to make repayments by payment vouchers

I confirm, to the best of my knowledge the information I have provided is true and correct. However, should my circumstances change I will notify you immediately.

Signed: ………………………………… Date: ……………………