Income and expenditure form 

Name: 		
Address:	                	
Payment Reference: 	                	

INCOME	
     Income	         
        How Often	Weekly Total	Monthly Total	
Earned Income(after tax+NI)	£		£	£	
Partner’s Income (after tax+NI)	£		£	£	
Statutory Sick Pay	£		£	£	
Working Tax Credit	£		£	£	
Universal Credit	£		£	£	
JSA (Contribution)	£		£	£	
JSA (Income based)	£		£	£	
ESA	£		£	£	
Income Support	£		£	£	
Child Benefit 	£		£	£	
Child Tax Credit	£		£	£	
Carer’s Allowance	£		£	£	
PIP / DLA Care	£		£	£	
PIP / DLA Mobility 	£		£	£	
Maternity Allowance 	£		£	£	
Pension Credit	£		£	£	
State Pension 	£		£	£	
Private Pension	£		£	£	
Partner’s State Pension	£		£	£	
Partner’s Private Pension	£		£	£	
Attendance Allowance	£		£	£	
Industrial Injuries Benefit 	£		£	£	
Other	£		£	£	
	Total Income	£	£	

EXPENDITURE	
Expenditure	
How  Often	Weekly Total	Monthly Total	
Net Rent	£		£	£	
Rent Arrears	£		£	£	
Council Tax (incl arrears)	£		£	£	
Water Rates (incl arrears)	£		£	£	
Gas (incl arrears)	£		£	£	
Electricity (incl arrears)	£		£	£	
Housekeeping (food)	£		£	£	
Clothing/Maintenance	£		£	£	
School Meals	£		£	£	
Childcare Costs	£		£	£	
Travel Expenses 	£		£	£	
TV License	£		£	£	
Mobile/Landline	£		£	£	
Internet	£		£	£	
Sky/Digital/Cable	£		£	£	
Car Finance/Insurance	£		£	£	
Loans/Credit/Store Cards	£		£	£	
Catalogues	£		£	£	
Medical Costs	£		£	£	
Fines 	£		£	£	
Other	£		£	£	
	Total Expenditure	£	£	
	Disposable	£	£