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Monthly Financial Statement


	Date:
	Applicant Name:
	Partner Name:
	Current Address:
	Town/City
	County:
	Post Code:
	Number of people in the household:
	Number of children:
	Children Ages:

	Amount quoted is nearest to the £
	Income
	1st Salary
	2nd Salary
	Part Time Job
	Family Credit
	Income Support
	Incapacity Benefit
	Child Benefit
	Unemployment Benefit
	Disability Benefit
	Retirement Pension
	State Pension
	Maintenance
	Contributions
	Rent and Other income

	Total Monthly Income

Amount quoted is nearest to the £

Essential Expenditure

Rent

Ground rent & service charges

Mortgage

Secured Loans

Endowment and MPPI

Building and contents insurance

Pension and life insurance

Council Tax

Gas

Electricity

Water

TV licence should £12.00 a month

Court fines

Maintenance or child support

Hire Purchase / conditional sale

Childcare costs

Adult care costs

Other

Phone Bills

Home phone Land line

Mobile phone/s

Internet Package with Home phone land line

Other

Travel Expenses

Public transport (work, school,
shopping, taxi etc)

Car insurance

Road tax

Fuel (Petrol, Diesel, Oil etc)

MOT and car maintenance

Breakdown or recovery

Parking charges or tolls

Other

Housekeeping

Groceries

Clothing and footwear

Dentist, glasses, prescriptions,
hairdressing

Meals at school and at work

Pet food

Vet bills and pet insurance

Household Repairs

Other

Total Monthly Expenditure

Monthly Income less Monthly
Expenditure = Amount Available to pay
to your Creditors (Disposable Income)

Fill the amount you owe to your creditors to calculate the pro rata payments

Amount you owe to your creditors to the Nearest £

Your Disposable Income

Creditor

Account Number

Debt

Pro Rata

Total amount you owe to your CREDITORS

Information provided is an accurate record of my/our finances and I am willing to provide documentary proof if required.

Applicant Signature:

Partner Signature:

Date Financial Statement signed: