St Mungo’s, Midshire

Confidential Income Declaration Form

Please tick the box that is nearest to your total income from all sources after tax.Please tick one box only.

My total income is

Per Year / Per Month / Per Week
A / No income / No income / No income
B / £1 – £5,000 / lessthan £417 / less than £96
C / £5,001 – £10,000 / £418 – £833 / £97 – £192
D / £10,001 – £15,000 / £834 – £1,250 / £193 – £288
E / £15,001 – £20,000 / £1,251 – £1,667 / £289 – £385
F / £20,001 – £27,500 / £1,668 – £2,292 / £386 – £529
G / £27,501 – £35,000 / £2,293 – £2,917 / £530 – £673
H / £35,001 – £42,500 / £2,918 – £3,542 / £674 – £817
I / £42,501 – £50,000 / £3,543 – £4,167 / £818 – £962
J / £50,001 – £60,000 / £4,168 – £5,000 / £963 – £1,154
K / £60,001 – £70,000 / £5,001 – £5,833 / £1,155 – £1,346
L / £70,001 – £80,000 / £5,834 – £6,667 / £1,347 – £1,538
M / more than £80,000 / more than £6,667 / more than £1,538

Notes

Enter your personal income only, not income received by your partner or other members of your family.

Enter yourtotal income after tax and National Insurance;includeearnings, salary, stipend, wages, pensions, intereston savingsaccounts, incomefrom investments, dividends etc.

Please ensure that you only declare your income once. If you are involved with more than one church please either participate in just one survey or divide your income between the different surveys.

Once Completed

  1. Please place this form in the sealed box in Church marked INCOME
  2. If you are unable to take the forms to Church yourself, place this form in a sealed envelope, marked INCOME, and send it to one of the Churchwardens, or get someone to take it to Church for you.

Thank you for your help in completing this form.

Remember: the separate forms and boxes are to
maintain confidentiality.Thank you for your help.