Financial assessment form

Financial assessment

Please use this form to request instalments for your Housing Benefit overpayment.

Invoice number / Benefit claim number: *

Partner

Do you have a partner? *

Yes
No

Partner details

Full name: *

Date of birth: *

National insurance number: *

Other household members

Are there any other members of the household? *

Yes
No

Other household members

Income details

Please make sure you include all income you receive and be as accurate as possible. This will help us calculate the correct payment.

Earnings

Do you work for an employer? *

Yes
No

Employment details

House name/number:

Postcode: *

Benefits

Do you currently receive any benefits: *

Yes
No

Benefits

Please add all benefits you receive.

Capital

Do you have money in any bank, building society or Post Office accounts? *

Yes
No

Partner's income details

Please make sure you include all income your partner receives and be as accurate as possible. This will help us calculate the correct payment.

Earnings

Does your partner work for an employer? *

Yes
No

Partner's employment details

House name/number:

Postcode: *

Partner's self-employed details

Is your partner self-employed? *

Yes
No

Partner's benefits

Does your partner currently receive any benefits? *

Yes
No

Partner's benefits

Please add all the benefits your partner receives.

Partner's capital

Does your partner have money in any bank, building society or Post Office accounts? *

Yes
No

Debts you owe

Please tell us about all arrears and money you owe.

Council debts

Council tax: *

Yes
No

Business rates: *

Yes
No

Car parking: *

Yes
No

Other invoices: *

Yes
No

How much can you pay?

What is the maximum you can afford to pay? *

How often can you pay this? *

Weekly
Fortnightly
Monthly

Providing evidence

You will need to provide three months consecutive bank statements for all accounts you have.

To consider this offer we must receive your bank statements. If we don’t receive these within 14 days we will not consider this offer. We will not write to tell you this.

Do you want to upload these now? *

Yes
No

Supplying your bank statements at a later date

If you do not provide them, further recovery action will be taken which could result in your debt being passed to the collection agent or money being taken directly from your earnings or benefits.

You can upload them or send them by post, further details will be included in your confirmation email.

Submitting your bank statements

Bank statements: *

Bank statements:
Optional

Other information

Is there anything else you think we should know about when making our decision?

User:

Lookup contact details:
Enter the Civica contact number

Contact details

First name: *

Surname: *

Contact details

House name/number:

Postcode: *

Contact details

Email address:

Telephone number:
If we call you our number will be withheld.

Data protection

The information you have provided on this form will be used to deal your request by the relevant department. We may pass your details on to contracted third party service providers. We will store a copy of your completed request as a backup for 12 months.

If you would like to know more about how we use your information and how you can exercise your information rights please see our privacy notice.

Do you accept these terms and conditions