Financial Statement Please complete and return this form Your Account DetailsAccount NumberYour Full NameYour Postcode 1 Household Details Number in Household Number of Dependants Ages of Each Dependant Monthly Income Per Month Your Employers Name Your Earnings (incl. Regular O/T Commission Bonus etc.) Your Partners Earnings Child Benefit Income Support Family Tax Credit Jobseekers Allowance Disability Benefit Pension Child Maintenance Recd Rent You Receive Contributions from Others (incl. dependants) Other Income Total Monthly Income (A) 3 Other expenditure Monthly Expenditure Per Month Food and Housekeeping School Meals Tobacco Clothing/Footwear Healthcare Child Minder/Nursery Life Assurance/Pension Building/Content Insurance Telephone Rented Items TV/Satellite/Video Leisure Activities Travel Expenses Car Insurance Service/Repairs Other (please specify below) Total Other Expenditure (C) 2 Priority expenditure Monthly Expenditure Arrears (if any) Payment Per Month Rent/Board/Mortgage Please Specify 2nd Mortgage/Secured Loan Endowment Policy Service Charge/Ground Rent Council Tax Water Gas Electric Child Maintenance Paid by You Court Fines Vehicle Finance/Hire Purchase TV Licence Other (specify) Total Priority Expenditure (B) 4 Income available to pay other debts How to work out available income to pay other debts A B C D Total Monthly Income (A) Total Priority Expenditure (B) Total Other Expenditure (C) Available income to pay other debts (D) 5 Offer of payment