Housing Benefit Invoice Financial Questionnaire

You are being asked to provide a clear, complete and accurate picture of your current and recent financial situation for your request to repay your invoice by instalments to be considered; you must include details of anyone who also shares financial responsibility with you.

Housing Benefit details

Housing Benefit invoice number(Required)

Your details

Title(Required)

Please specify title(Required)

First name(Required)

Last name(Required)

Other names

Marital status(Required)

Address details

Do you live in Redbridge?(Required)

Yes

No

Address(Required)

Find address

Address(Required)

Street Address City County Postcode

Contact details

Contact telephone number(Required)

Alternative contact number

Email

Enter Email Confirm Email

Household details

Number of people in household (including dependents)(Required)

Number of dependent children under 18

Are you in receipt of a DWP prescribed benefit?(Required)

Yes

No

Are you currently in employment?(Required)

Yes

No

Are you self-employed?(Required)

Yes

No

Self-employment details

Name of business(Required)

Type of business(Required)

Business address details

Is your business in Redbridge?(Required)

Yes

No

Address(Required)

Find address

Address(Required)

Street Address City County Postcode

Employer details

Name of the employer(Required)

Pay number(Required)

Is your employer in Redbridge?(Required)

Yes

No

Employer address and contact details

Address(Required)

Find address

Address(Required)

Street Address City County Postcode

Telephone number(Required)

Property details

Do you own the property that you are residing in?(Required)

Yes

No

Is the property jointly owned?(Required)

Yes

No

Please enter the name of the joint owner/s

First name	Last name	Actions

There are no Entries.

Property address

Is your property in Redbridge?(Required)

Yes

No

Is your property in the UK or overseas?(Required)

Property is in the UK

Property is overseas

Address(Required)

Find address

Address(Required)

Street Address Address Line 2 City County Postcode

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Other properties

Do you own/joint own any other properties (including any overseas)?(Required)

Yes

No

Is your other property in Redbridge?(Required)

Yes

No

Is the other property in the UK or overseas?(Required)

Other property is in the UK

Other property is overseas

Address of other property owned(Required)

Find address

Address of other property owned(Required)

Street Address City County Postcode

Address of other property owned(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Additional property

Do you want to add another property you own or jointly own?

Yes

No

Is the additional property in Redbridge?(Required)

Yes

No

Is the additional property in the UK or overseas?(Required)

Additional property is in the UK

Additional property is overseas

Address(Required)

Find address

Address of the additional property(Required)

Street Address City County Postcode

Address of the additional property

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Spouse/Partner's details

Title(Required)

If other, please specify(Required)

First name(Required)

Last name(Required)

Other names

Is your spouse/partner in receipt of a DWP prescribed benefit?(Required)

Yes

No

Is your spouse/partner currently in employment?(Required)

Yes

No

Is your spouse/partner self-employed?(Required)

Yes

No

Spouse/Partner's self-employment details

Name of business(Required)

Type of business(Required)

Spouse/Partner's business address details

Is your spouse/partner's business in Redbridge?(Required)

Yes

No

Address(Required)

Find address

Address(Required)

Street Address City County Postcode

Spouse/Partner employer details

Name of spouse/partner's employer(Required)

Is your spouse/partner's employer in Redbridge?(Required)

Yes

No

Spouse/Partner's employers address and contact details

Address(Required)

Find address

Address(Required)

Street Address City County Postcode

Telephone number(Required)

Your monthly income

Work through the fields below to give us clear picture of how much money you have coming into your household each month. If the field is not applicable please enter zero.

DWP prescribed benefit £

Please enter a number greater than or equal to 0.

Your earnings £

This is how much money you take home each month after tax

Please enter a number greater than or equal to 0.

Your partner's earnings £

This is how much money your partner takes home each month after tax

Please enter a number greater than or equal to 0.

Private pension £

Please enter a number greater than or equal to 0.

Housing Benefit £

Please enter a number greater than or equal to 0.

Council Tax reduction £

Please enter a number greater than or equal to 0.

Child Tax Credit £

Please enter a number greater than or equal to 0.

Working Tax Credit £

Please enter a number greater than or equal to 0.

Child Benefit £

Please enter a number greater than or equal to 0.

Child maintenance £

Please enter a number greater than or equal to 0.

Grant/Loans/Bursary £

Please enter a number greater than or equal to 0.

Rental/Board received £

Please enter a number greater than or equal to 0.

Other income

Do you receive any other income?

Yes

No

Specify income type(Required)

£(Required)

Add income

Add another income

Specify income type(Required)

£(Required)

Add income

Add another income

Specify income type(Required)

£(Required)

Add income

Add another income

Specify income type(Required)

£(Required)

Your monthly expenditure

Work through the fields below to give us clear picture of how much money you have going out of your household each month. If the field is not applicable please enter zero.

Mortgage £

Please enter a number greater than or equal to 0.

Rent £

Please enter a number greater than or equal to 0.

Service charges £

Please enter a number greater than or equal to 0.

Secured loans £

Please enter a number greater than or equal to 0.

Non-secured loans £

Please enter a number greater than or equal to 0.

Credit cards £

Please enter a number greater than or equal to 0.

Council Tax £

Please enter a number greater than or equal to 0.

Water £

Please enter a number greater than or equal to 0.

Gas/Electric £

Please enter a number greater than or equal to 0.

Telephone £

Please enter a number greater than or equal to 0.

Mobiles £

Please enter a number greater than or equal to 0.

Internet £

Please enter a number greater than or equal to 0.

Satellite/Cable £

Please enter a number greater than or equal to 0.

TV Licence £

Please enter a number greater than or equal to 0.

Child maintenance £

Please enter a number greater than or equal to 0.

Child care costs £

Please enter a number greater than or equal to 0.

Buildings/Contents insurance £

Please enter a number greater than or equal to 0.

Life insurance £

Please enter a number greater than or equal to 0.

Car insurance £

Please enter a number greater than or equal to 0.

Road tax £

Please enter a number greater than or equal to 0.

Fuel £

Please enter a number greater than or equal to 0.

Public transport fares £

Please enter a number greater than or equal to 0.

Household shopping £

Please enter a number greater than or equal to 0.

Other expenditure

Any other expenditure?

Yes

No

Specify expenditure type(Required)

£(Required)

Add expenditure

Add another expenditure

Specify expenditure type(Required)

£(Required)

Add expenditure

Add another expenditure

Specify expenditure type(Required)

£(Required)

Add expenditure

Add another expenditure

Specify expenditure type(Required)

£(Required)

Monthly instalment payment offer

What is your offer of a monthly instalment payment?*(Required)

Your offer is not guaranteed as being accepted and any offer agreed is also subject to periodic reviews.

Written confirmation of agreement will be either e-mailed or posted within 14 days of being received.

You should make some form of payment whilst your request is being dealt with.

Evidence upload

Please upload last 2 month’s bank/building society statements to support income/expenditure declared

Upload statements

Drop files here or

Max. file size: 50 MB.

Are you completing this form on behalf of someone else?(Required)

Yes

No

Your details

First name(Required)

Last name(Required)

Do you live in Redbridge(Required)

Yes

No

Address(Required)

Find address

Address(Required)

Street Address City County Postcode

Your contact details

Telephone number(Required)

Mobile number

Email address

Enter Email Confirm Email

Declaration

Please tell us why you are filling in this form for someone else(Required)

Declaration

I declare that the information I have given is complete and accurate to the best of my knowledge. I understand that the Council may check the information against other data sources and that the option to pay by instalments may be withdrawn if I knowingly supply false information.