Household Income Form

Household Income Form - Page 2

If you would like any help or advice with this form, please:

Telephone : 01352 704848. This helpline is open Monday to Friday 8:30am-5pm.

Email : local.taxation@flintshire.gov.uk

By continuing this form you consent to providing correct, up to date and accurate data.

Household Income Form - Page 3

Personal Details

Surname:

First Names:

Address

Mobile Phone Number:

Email Address:

How many occupants over 18 are in the property:

How many dependants (persons under 18) are in the property:

Outstanding balances

Council Tax (Amount) :

Business Rates (if applicable) :

Other Debt (if applicable) :

Do you owe Council Tax to any other Local Authority (not including the authority you're applying to)?:

Yes No

About Household Income

Are you self-employed?

Yes No

How often do you get paid? Every (weekly / fortnightly / monthly)

Net Pay (If you have nil earnings please enter £0.00)

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Please answer all questions

Other sources of income

Money received from other people (£):

Other income:

Realisable assets / Potential income:

Any other comments about your income:

Mortgage Amount (£):

Every (Frequency)

Rent Amount (£):

Every (Frequency)

2nd Mortgage Amount (£) if applicable:

Every (Frequency)

Secure Loan Amount (£):

Every (Frequency)

Unsecure Loan Amount (£):

Every (Frequency)

Ground Rent Amount (£):

Every (Frequency)

Service Charges Amount (£):

Every (Frequency)

Home Insurance Amount (£):

Every (Frequency)

Life Insurance Amount (£):

Every (Frequency)

Council Tax Amount (£):

Every (Frequency)

Gas Amount (£):

Every (Frequency)

Electricity Amount (£):

Every (Frequency)

Water Amount (£):

Every (Frequency)

Food / Housekeeping Amount (£):

Every (Frequency)

Hire Purchase Amount (£):

Every (Frequency)

Car Tax / Insurance Amount (£):

Every (Frequency)

Telephone Amount (£):

Every (Frequency)

Sky / Cable Amount (£):

Every (Frequency)

TV Licence / Rental Amount (£):

Every (Frequency)

Clothes Amount (£):

Every (Frequency)

Health Costs Amount (physiotherapy) (£):

Every (Frequency)

Clubs Amount (£):

Every (Frequency)

Fines Amount (£):

Every (Frequency)

Maintainance Amount (£):

Every (Frequency)

Gym Membership Amount (£):

Every (Frequency)

Credit cards Amount (£):

Every (Frequency)

Store Cards Amount (£):

Every (Frequency)

Alcohol Amount (£):

Every (Frequency)

Cigarettes Amount (£):

Every (Frequency)

Travel Expenses (Petrol/Bus Fees) Amount (£):

Every (Frequency)

Pet (Food / Insurance) Amount (£):

Every (Frequency)

Other expenses Amount (£):

Every (Frequency)

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If any of the payments are due to end in the next 12 months please tell us which one and the date its due to finish?

Payment Name

Communication With Applicants

The Council will notify in writing all applicants for discretionary discounts of its decision.

Where a discretionary discount is granted, the notification will include:

The amount of discretionary granted and the effective date of the award

The start and end date of the award

The new chargeable amount (if any)

A requirement that the applicant should notify the Council of any relevant change in circumstances that may affect the award

Where applications are unsuccessful the Council will provide a decision letter to properly inform the taxpayer of the reason for the application being unsuccessful. The decision letter will explain the appeal rights if the taxpayer is unhappy with the outcome of the decision.

Declaration

I declare that the information provided is true and accurate to the best of my knowledge and authorise the Council to make any enquiries necessary to verify it. I understand that I am obligated to inform the Council of any change in circumstances.

Name of person who filled in the form:

Date:

Is there any other information you would like us to know? Please enter it here:

Household Income Form

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