Income

Amount (£)

Debtor’s salary/wages

Partner’s salary/wages

Pension(s)

Amount (£)

State Pension(s)

Private or  work pension(s)

Pension Credit

Other income

Amount (£)

Maintenance or child support

Boarders or lodgers

Non-dependant contribution

Student loans or grants

(To be completed with any
other household income)

Type of benefit

Amount (£)

Jobseeker’s Allowance

Income Support

Working Tax Credits

Child Tax Credits

Employment and Support Allowance

DLA, PIP or Attendance Allowance

Carer’s Allowance

Housing Benefit/Local Housing Allowance

Council Tax Reduction

Universal Credit

(Other)

(Other)

(Other)

Essential expenditure

Amount

Rent

Ground rent, service charges, factor fees

Mortgages

Other Secured Loans

Building and Content Insurance

Pension and Life insurance

Council Tax

Gas

Electricity

TV Licence

Magistrates or Sheriff Court Fines

Maintenance or Child Support

Hire Purchase/Conditional Sales

Childcare Costs

Adult Care Costs

Phone

Amount

Home Phone

Mobile Phone(s)

Travel

Amount

Public Transport (work, school, shopping, etc)

Car Insurance

Vehicle Tax

Fuel (Petrol, Diesel, Oil, etc)

MOT and car maintenance

Breakdown and Recovery

Parking Charges or Tolls

Housekeeping

Amount

Food and Milk

Cleaning and Toiletries

Newspapers and Magazines

Cigarettes Tobacco and Sweets

Alcohol

Laundry and dry cleaning

Clothing and Footwear

Nappies and baby items

Pet Food

Amount

Health (dentist, glasses, prescriptions, health insurance)

Repairs/house maintenance (including window cleaning, maintenance contracts)

Hairdressing/haircuts

Cable, Satellite and Internet

TV, video and other appliance rental

School meals and meals at work

Pocket money and school trips

Lottery and Pools etc.

Hobbies/leisure/sport (include pub outings, etc.)

Gifts (Christmas Birthday, Charity etc.)

Vet Bills and Pet Insurance

All other expenses not covered above

Amount

1.

2.

3.