Statement of Means

Name ______Reference ______

Occupation ______Place of Employment ______

Household
Number of Adults
Number of Children
Ages of Children & Education Status ie. Primary, Secondary, 3rd Level
Income / £ / Comments
Wages / Salary
Rent Received
Pension(s)
Disability Living Allowance
Incapacity Benefit
Tax Credits
Child Benefit
Other
Expenses / £ / Comments
Housing
Rent / Rent Arrears £
Mortgage / Mortgage Arrears £
Secured loan/2nd Mortgage / Secured Loan / 2nd Mortgage Arrears £
Mortgage Endowment Premium
Ground Rent
Rates
Gas
Electricity
Other Household Fuels
Household Services
Building & Contents Insurance
Telephone incl. Mobile/Internet
TV License
Satellite Rental
Child Support Paid by You
Childcare
Fines, CCJs etc
Life Assurance/Private Pensions
Medical / Accident Insurance
Motoring
Vehicle Finance
Spares/Servicing
Road Tax
Insurance
Fuel & parking
Fares & Travel
Food & Housekeeping
Food, Toiletries, Cleaning
School Meals / Meals at work
Pets, Pet Food/Insurance
Tobacco
Clothing & Footwear
Misc. Goods & Services
Dentist / Opticians
Hairdressing
Sundres / Emergencies
Self Employed
Income Tax
National Insurance
VAT
TOTAL EXPENSES
TOTAL INCOME
SURPLUS/DEFICIT

When calculating monthly outgoings/expenditure you should detail all of your expenditure even if it is paid less frequently than monthly eg. All insurances, electric/gas/TV licence, transport costs etc.

Liabilities / Other Debts

Creditor/Financial Institution / Amount Owed / Payment Amount / Payment Frequency

Proposed Repayment Plan:

Amount: £ Frequency: Weekly □ / Fortnightly □ / Monthly □

Expected time within which you expect to discharge our Client’s debt :

Assets/Property

______

NOTE

Please ensure that all questions in this form are fully answered. Where a question is not applicable, please mark "N/A". Failure to fully complete the Statement of Means form will result in the form being returned to you looking for the missing information.

PLEASE NOTE THE FOLLOWING SUPPORTING DOCUMENTS MAY BE REQUIRED

(Note – All documents must be the most recent available. Note: you can provide a copy of a winter and summer bill for utilities that may change significantly over the year e.g. gas or electricity. Failure to include any such requested documents will mean that we are unable to rely on the form as proof of your stated current financial position).

  • Your payslip(s) in respect of your employment(s)
  • Your Unemployment Benefit/Assistance payslips (as applicable)
  • Your Disability Allowance payslips (as applicable)
  • Your Old Age Pension Allowance payslips (as applicable)
  • Bank, Credit Union and Post Office Statements (as applicable) of all current, loans and savings accounts
  • Copy Agreements made with other Creditors
  • Any evidence available to show the contributions from the other adult members of the household e.g. Standing Order payment amount

DECLARATION

By sending this information, I declare that all of the information entered onto and enclosed in this Statement of Financial Means, which includes those documents, original or otherwise, attached hereon, to represent a true, factual and authentic account of my current circumstances. I accept that should DRA alter their position on foot of the declarations made herein; declarations which include accompanying documents, original or otherwise attached hereon, legal proceedings maybe instigated against me if it is subsequently found that the said declarations are false or inaccurate.