Confidential Income Statement

ISSUE DATE:______

Confidential Income Statement

(Income for period1st January 2014 to 31st December 2014

Plusdetails of current income)

First Name(s)………………………………..Surname………………………….…....

Address:………………………………………………………………………………

……………………………………………….Telephone:……………………………

Email:………………………….. Emergency Contact No: ………………………

This form must be completed and supporting documentation provided by the required date in order to enable us to assess your rent.

If you require any assistance in completing this form please contact your local office.

MEMBERS OF HOUSEHOLD

(I.e. ALL MEMBERS RESIDING AT THE PROPERTY)

NAME / NATIONALITY / M/F / DATE OF BIRTH / P.P.S No

DETAILS OF INCOME

We require income details for you and all members of your household who reside at the property.

PLEASE COMPLETE ALL RELEVANT SECTIONS

a)INCOME FROM DEPARTMENT OF SOCIAL WELFARE

Type of allowance/ assistance (e.g. Lone-Parents, Disability) / Name of person(s) who received allowance/ assistance / Periodfor which allowance/ assistance was received (i.e from date to date) / Amount of allowance/ assistance per week

Evidence of this income must be provided by:

a) Social Welfare Receipts/ Bank Statements (3 current receipts required)

b) attached form completed by the Dept of Social Community and Family Affairs

b)INCOME FROM EMPLOYMENT AND/OR FAMILY INCOME SUPPLEMENT

Type of employment (i.e. full/ part-time or CE /Tus Scheme) / Name(s) of person employed / Period of employment (i.e. dateto date) / Weekly or monthly take home pay

Evidence of this income must be provided by:

a)P60 for year 1 January 2014 to 31st December 2014 and 3 current pay slips.

b)A letter confirming attendance at and duration of CE/ Tus Scheme.

c)INCOME FROM OTHER SOURCE

Type of income (e.g. child maintenance and child benefit) / Name of person(s) who received income / Period income was received (i.e. dateto date) / Weekly or monthly amount received

Please provide written proof of this income

3.(a) ARE ANY OF YOUR DEPENDANTS AGED 18 OR OVER AND IN FULL-TIME EDUCATION? YES / NO

If yes, please provide a letter from the School or College confirmingtheir attendance.

If no, please provide the date they left Full Time Education in the box below and details of their income, such as payslips, or a letter of confirmation from the Dept of Social Community and Family Affairs

Date left Full Time Education: ______
Current Weekly Income is € ______

(b) PARTICULARS OF PERSON(S) WHO HAVE LEFT THE PROPERTY SINCE THE SUBMISSION OF THE LAST RENT ASSESSEMNT FORM.

NAME / M/F / DATE OF BIRTH / P.P.S No

4 SELF EMPLOYED PERSON

PART A

CERTIFICATE OF BASIC PAY TO BE COMPLETED AND CERTIFIED BY A CERTIFIED ACCOUNTANT

Name of Self Employed Person ______

Address ______

Current Weekly Pay/ Drawdown€______

Less (a)Income Tax on Basic Pay€______

(b)Social Welfare Contribution€______

Deductions (a) & (b)

NETT Basic Pay€______

PPS No. ______Date of Birth ______

Gross Earning to Year Ended 31st December 2014 ______

Tax Paid to Year Ended 31st of December 2014 ______

Date of Commencement of Self Employment ______

Please comment on material changes since 2013 ______

I hereby certify as correct the above details in collection with the employment and Income of the above named.

Accountants Signature______Date: ______

Accountants Address: ______

Telephone Number: ______

Accountants Official Stamp: ______

PART B

I hereby authorise Túath Housing to seek and receive information from my Accountant in relation to income payable to me.

Signed: ______Date: ______

4 CERTIFCATION FROM DEPARTMENT OF SOCIAL WELFARE

(this section must be completed and signed by Department of Social Welfare)

Name ______PPS No: ______

Address:______

Date:______

Re: (A) Confirmation of Current Allowance/ Assistance received

Payment Type / Dates received from/ to / Amount

Re: (B) Confirmation of Allowance/ Assistance received from 1st January 2014 to 31st of December 2014

Payment Type / Dates received from/ to / Amount

Signed:……………………………………..

Social Welfare Branch:………………………………….Official Stamp

Telephone:…………………………………

Date:……………………………………….

DECLARATION

I confirm that the above information is accurate to the best of my knowledge.

I authoriseTúath Housing to validate my income with the Department of Social, Community and Family Affairs or the Community Welfare Officer if required.

Signed:………………………………………Date:…………………