Income and Expenditure Form Template
Income and expenditure form
Date
Sent:
Name:
Address:
Reference number:
Personal budget
Your income (We need to see
proof of all your income.)
Weekly Monthly
Your wages
£ £
Please provide your
employers full name and
Your partner’s wages
£ £
address on page 3
Company pension
£ £
Income Support
£ £
Jobseeker’s Allowance
£ £
Child Benefit
£ £
Working Tax Credit
£ £
Child Tax Credit
£ £
Incapacity Benefit
£ £
Pension Credit
£ £
Bereavement benefit
£ £
Carers’ allowance
£ £
Other state benefits-please
specify
£ £
£ £
Maintenance
£ £
Money from anyone who lives with
you
£ £
Housing Benefit
£ £
Council Tax Benefit
£ £
Student loan/grant
£ £
Insurance Payments
£ £
Other – please specify
£ £
Total income
£ £
Your spending (We need to see
proof of all regular spending.)
Weekly Monthly
Mortgage payments
£ £
Mortgage protection policy
£ £
Second mortgage or a loan which
your home is security for
£ £
Life assurance or endowment
premiums
£ £
Rent
£ £
Council Tax
£ £
Ground Rent
£ £
Buildings and contents insurance
£ £
Utilities:
Water Charges
£ £
Electricity
£ £
Gas
£ £
Other fuel or heating costs
£ £
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