Council Tax Liability Order Request for Information

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Your Details

Forename

Surname

Phone Number

Email Address

Address

Recently Used Address

Address

If you are using a screen reader, do not fill in this field If you are using a screen reader, do not fill in this field

Enquiry Details

Failure to complete this form in full or make payment in full within 14 days of the Liability Order will result in your arrears being escalated to further recovery which may include being passed to an Enforcement Agent and you will be liable to pay their additional fees or contacting your employer for direct deductions.

Council Tax Reference Number

Do you rent or own the property?

Rent Own

Please give details of all persons over the age of 18 (Starting with yourself) who are living in your home.

Title

First Name

Surname

DOB

NI Number

Please confirm your Employment status

Employed Self-employed Not Employed Retired

Is your Partner employed or self-employed?

Yes No

Is your Partner employed or self-employed?

Yes No

Please can this individual complete their own form on their behalf.

Please provide the details of the employer referred to above

Name of Employer

Telephone Number of Employer

Address of Employer

Please provide your Payroll OR National Insurance Number

Please state how often you get paid

Weekly Fortnightly Monthly

Please state your net earnings after deductions

Are you receiving sick pay from your employer?

Yes No

Do you receive Universal Credit?

Yes No

Do you receive Income Support?

Yes No

Are you the

Claimant Partner to Clamant

Please state your National Insurance Number

What is your Date of Birth

Do you receive any of the following?

Job Seeker's Allowance Employment Support Allowance Pension Credit

If your source of income is not listed, please confirm where your income is from

Would you like to add another person?

Yes No

Title

First Name

Surname

DOB

NI Number

Please confirm your Employment status

Employed Self-employed Not Employed Retired

Is your Partner employed or self-employed?

Yes No

Is your Partner employed or self-employed?

Yes No

Please can this individual complete their own form on their behalf.

Please provide the details of the employer referred to above

Name of Employer

Telephone Number of Employer

Address of Employer

Please provide your Payroll OR National Insurance Number

Please state how often you get paid

Weekly Fortnightly Monthly

Please state your net earnings after deductions

Are you receiving sick pay from your employer?

Yes No

Do you receive Universal Credit?

Yes No

Do you receive Income Support?

Yes No

Are you the

Claimant Partner to Clamant

Please state your National Insurance Number

What is your Date of Birth

Do you receive any of the following?

Job Seeker's Allowance Employment Support Allowance Pension Credit

If your source of income is not listed, please confirm where your income is from

Would you like to add another person?

Yes No

Please give details of all persons over 16 years of age (including yourself) who are living in your home. Please incluide the date of birth for those persons aged 16 or 17

Title

First Name

Surname

DOB

NI Number

Please confirm your Employment status

Employed Self-employed Not Employed Retired

Is your Partner employed or self-employed?

Yes No

Is your Partner employed or self-employed?

Yes No

Please can this individual complete their own form on their behalf.

Please provide the details of the employer referred to above

Name of Employer

Telephone Number of Employer

Address of Employer

Please provide your Payroll OR National Insurance Number

Please state how often you get paid

Weekly Fortnightly Monthly

Please state your net earnings after deductions

Are you receiving sick pay from your employer?

Yes No

Do you receive Universal Credit?

Yes No

Do you receive Income Support?

Yes No

Are you the

Claimant Partner to Clamant

Please state your National Insurance Number

What is your Date of Birth

Do you receive any of the following?

Job Seeker's Allowance Employment Support Allowance Pension Credit

If your source of income is not listed, please confirm where your income is from

Would you like to add another person?

Yes No

Please give details of all persons over 16 years of age (including yourself) who are living in your home. Please incluide the date of birth for those persons aged 16 or 17

Title

First Name

Surname

DOB

NI Number

Please confirm your Employment status

Employed Self-employed Not Employed Retired

Is your Partner employed or self-employed?

Yes No

Is your Partner employed or self-employed?

Yes No

Please can this individual complete their own form on their behalf.

Please provide the details of the employer referred to above

Name of Employer

Telephone Number of Employer

Address of Employer

Please provide your Payroll OR National Insurance Number

Please state how often you get paid

Weekly Fortnightly Monthly

Please state your net earnings after deductions

Are you receiving sick pay from your employer?

Yes No

Do you receive Universal Credit?

Yes No

Do you receive Income Support?

Yes No

Are you the

Claimant Partner to Clamant

Please state your National Insurance Number

What is your Date of Birth

Do you receive any of the following?

Job Seeker's Allowance Employment Support Allowance Pension Credit

If your source of income is not listed, please confirm where your income is from

Would you like to receive your future Council Tax bills via email?

Yes No

Your Proposals for Payment

Please outline below your proposals to pay the outstanding Council Tax amount. Your proposals will be considered and a reply will be sent to you to confirm whether or not this is acceptable. You should start making payments immediately.

Household monthly net income including all members of your household

Your own individual net monthly income

Proposed Payment

How would you like to make this payment?

Direct Debit Any other payment method (Such as cash)

Frequency of payment

Weekly Monthly Other

Please specify other frequency

Your proposals will not be considered, and your account will be passed to the Enforcement Agent, if you do not fully complete all relevant questions

Bank name

Name on the account

Sort Code

Account number

Building society roll number (if you have one)

Is this valid?

Instruction to Your Bank/Building Society

Please pay Flintshire County Council Direct Debits from the account detailed in this instruction, subject to the safeguards assured by the Direct Debit Guarantee.

I understand that this instruction may remain with Flintshire County Council and, if so, details will be passed electronically to my Bank/Building Society

Signed (Full Name)

Direct Debit Guarantee

Your rights

Organisations using the Direct Debit Scheme go through a careful vetting process before they are authorised, and are closely monitored by the banking industry. The efficiency and security of Direct Debit is monitored and protected by your own bank or building society.

The Direct Debit Guarantee applies to all Direct Debits. It protects you in the rare event that there is an error in the payment of your Direct Debit, for instance if a payment is taken on the incorrect date, or the wrong amount is collected. It cannot be used to address contractual disputes between you and the billing organisation.

Direct Debit Guarantee

The Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits
If there are any changes to the amount, date or frequency of your Direct Debit the organisation will notify you (normally 10 working days) in advance of your account being debited or as otherwise agreed. If you request the organisation to collect a payment, confirmation of the amount and date will be given to you at the time of the request
If an error is made in the payment of your Direct Debit, by the organisation or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society

If you receive a refund you are not entitled to, you must pay it back when the organisation asks you to

You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify the organisation.

Choose your payment date

This does not form part of your instruction to your bank/building society and is for Flintshire County Council official use only.

Please select your preferred payment date by ticking only one of the boxes below:

Please select only one payment date option

Monthly on 1st
Monthly on 8th
Monthly on 18th
Monthly on 25th
4 Weekly on a Monday
Weekly on a Monday

We will continue to request all future Council Tax payments by Direct Debit unless you cancel your Direct Debit with the bank or contact the Council directly to discuss your account. The Council must comply with the Direct Debit guarantee and will always notify the liable Council Tax payer in advance of any future payments that may be due.

I would like to extend my Council Tax payments to over 12 months

We normally will set up your instalments on your preferred date to cover your full Council Tax balance.

Declaration

The information I have given on this form is correct.

Your Full Name

Date signed