Financial support payment application form

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Record Type

ContactId

RecordId

Customer details

Council Tax account number

Name on council tax account

Address (including postcode)

Contact number

Household information

Is anyone living in the property in the armed forces or ex-armed forces

YesNo

Are there people over the age of 18 who live in the property?

YesNo

How many?

Name

Age

Details

Are there people under the age of 18 who live in the property?

YesNo

How many?

Name

Age

Details

Essential household outgoings

Please select and provide details of your essential household outgoings from the following

Rent/mortgage	Rent/mortgage arrears
Gas	Gas arrears
Electric	Electric arrears
Water charge (Affinity water)	Water arrears
Sewage charge (Southern water)	Sewage charge arrears
None

Rent/mortgage

Rent and mortgage (Amount in £'s)

How often?

Weekly

Monthly

Rent/mortgage arrears

Rent/mortgage arrears payments (Amount in £'s)

How often?

Weekly

Monthly

How much in total is owing on your rent/mortgage arrears (Amount in £'s)

Gas

Gas (Amount in £'s)

How often?

Weekly

Monthly

Gas arrears

Gas arrears payments (Amount in £')s

How often?

Weekly

Monthly

How much in total is owing on your gas arrears (Amount in £'s)

Electric

Electric (Amount in £'s)

How often?

Weekly

Monthly

Electric arrears

Electric arrears payments (Amount in £'s)

How often?

Weekly

Monthly

How much in total is owing on your electric arrears (Amount in £'s)

Water charge (Affinity water)

Water charge (Affinity) (Amount in £'s)

How often?

Weekly

Monthly

Water arrears

Water arrears payments (Amount in £'s)

How often?

Weekly

Monthly

How much in total is owing on your water arrears (Amount in £'s)

Sewage charge (Southern Water)

Sewage charge (Southern Water) (Amount in £'s)

How often?

Weekly

Monthly

Sewage charge arrears

Sewage charge arrears payments (Amount in £'s)

How often?

Weekly

Monthly

How much in total is owing on your sewage charge arrears (Amount in £'s)

Does your property have a cesspit or septic tank?

YesNo

Annual cesspit/septic tank cost

Annual cesspit/septic tank cost £'s

Other household costs

Which of the following do you pay for?

TV licence	Broadband	TV streaming services	Gaming services
None

TV licence

TV licence (Amount in £'s)

How often?

Weekly

Monthly

Broadband

Broadband (Amount in £'s)

How often?

Weekly

Monthly

Start date of current contract

Length of current contract

TV streaming services

Please tick all that apply

NetflixAmazon PrimeDisney +Discovery +Paramount +SkyOther

What is the total you pay each month for these services ? £

What is the total you pay each month for your TV streaming services ? £

Gaming services

Gaming services (Amount in £'s)

How often?

Weekly

Monthly

Which gaming service do you subscribe to?

Transport costs

Do you own a car?

Yes

Are you paying car finance?

YesNo

When did the contract start?

How long was the contract for?

How much do you pay each month £

What is the annual road tax for your car? £

How much do you pay for road tax each month? £

How much is your car insurance? £

How often?

WeeklyMonthly

Is you car insurance increased due to points on your licence?

YesNo

Is you car insurance increased due to a claim on your insurance?

YesNo

Is your car petrol, diesel, hybrid, fully electric?

PetrolDieselHybridFully electric

How much do you spend on fuel? £

How often?

WeeklyMonthly

Is you car serviced annually?

YesNo

Does your car require a yearly MOT certificate?

YesNo

Is there another vehicle in your household that you are responsible for?

YesNo

Other vehicle

What is the annual road tax for this vehicle? £

How much do you pay each month for road tax? £

How much is the insurance for this vehicle? £

How much do you pay each month for this vehicle insurance? £

Is the vehicle insurance increased because of points on your licence?

YesNo

Is the vehicle insurance increased due to a claim on your insurance?

YesNo

Is your vehicle petrol, diesel, hybrid or fully electric?

PetrolDieselHybridFully electric

How much do you spend on fuel? £

How often?

WeeklyMonthly

Is you vehicle serviced annually?

YesNo

Does your vehicle require a yearly MOT certificate?

YesNo

Other forms of transport

Do you use the bus on a regular basis ?

YesNo

How much do you spend on bus fares? £

How often?

Weekly

Monthly

What is the reason for your bus journeys?

Do you use taxis on a regular basis?

YesNo

How much do you spend on taxi fares? £

How often?

Weekly

Monthly

What is the reason for your taxi journeys?

Insurance

Do you have any of the following insurances?

House/home contents insuranceLife insurancePrivate medical insurancePet insuranceOther type of insuranceNone

Home insurance

How much do you spend on home/home contents insurance? £

How often?

Weekly

Monthly

Life insurance

How much do you spend on life insurance? £

How often?

Weekly

Monthly

Private medical insurance

How much do you spend on private medical insurance? £

How often?

Weekly

Monthly

Pet insurance

How much do you spend on pet insurance? £

How often?

Weekly

Monthly

Other types of insurance

How much do you spend on other types of insurance? £

How often?

Weekly

Monthly

What is the insurance for?

Pets

Do you have any pets?

YesNo

What pets do you have?

How much do you spend on pet food? £

How often?

Weekly

Monthly

Do you pay for regular flea treatment or worming treatment?

YesNo

How much do you spend on regular flea treatment or worming treatment? £

How often?

Weekly

Monthly

Do you have any other regular pet related costs?

YesNo

Please provide details

Personal costs

Which of the following personal costs do you have?

Groceries	Prescriptions
Smoking/vaping	Lifeline
Drinking	Gambling
Recreational drugs	Hairdressing
Opticians	Mobile phone
Gym subscription	Other clubs and hobbies (for those over 18 only)
Clothing (for those over 18 only)	Outgoings related to dependant children
Clothing (for children)	Child maintenance
Dentist

Groceries

How much do you spend on food, toiletries and cleaning products £'s

How often?

Weekly

Monthly

Smoking/vaping

How much do you spend on smoking/vaping? £

How often?

Weekly

Monthly

Prescriptions

How much do you pay on prescriptions? £

How often?

Weekly

Monthly

Lifeline

How much do you spend on Lifelife? £

How often?

Weekly

Monthly

Drinking

How much do you spend on drink? £

How often?

Weekly

Monthly

Gambling

How much do you spend on gambling? £

How often?

Weekly

Monthly

Recreational drugs

How much do you spend on recreational drugs? £

How often?

Weekly

Monthly

Hairdressing

How much do you spend on haircuts? £

How often?

Weekly

Monthly

Opticians

Do you wear contact lenses?

YesNo

How much do you spend on your contact lenses? £

How often?

Weekly

Monthly

Do you wear glasses?

YesNo

How much do you spend on your glasses? £

How often?

Weekly

Monthly

Do you get free eye tests?

YesNo

Mobile phone

How many phones do you pay for?

How much do you pay in total? £

How often?

Weekly

Monthly

Which of the following applies to your phone(s)?

ContractSim onlyPay as you go

Contract

How many are under contract?

Start date of contact?

Length of contract?

Did the contract include a new phone?

YesNo

How much do you pay? £

How often?

Weekly

Monthly

SIM only

How many are a SIM only deal?

How often?

Weekly

Monthly

How much do you pay? £

Pay as you go

How many are on PAYG?

How much do you pay? £

How often?

Weekly

Monthly

Gym subscription

Do you have a regular gym subscription?

YesNo

How much do you spend on regular gym subscriptions? £

How often?

Weekly

Monthly

Do you consider your gym subscription essential?

YesNo

Why do you consider your gym subscription essential?

Other clubs and hobbies (for those over 18 only)

Do you subscribe to other clubs or hobbies?

YesNo

How much do you spend on other clubs or hobbies? £

How often?

Weekly

Monthly

Do you consider the subscription to be essential?

YesNo

Why do you consider your subscription to be essential?

Clothing (for those over 18 only)

How much do you spend on clothing? £

How often?

Weekly

Monthly

Outgoings related to dependant children

Are your children (child) home educated?

YesNo

Do you have any other regular costs relating to the wellbeing of your child or children?

YesNo

Please provide details

Do your children (child) receive free school meals?

YesNo

Do you pay for school dinners?

YesNo

How much do you spend on school dinners? £

How often?

Weekly

Monthly

Do your children (child) attend any regular clubs?

YesNo

What do you spend on the regular clubs? £

How often?

Weekly

Monthly

Clothing (for children)

How much do you spend on clothing (including school uniform)? £

How often?

Weekly

Monthly

Child maintenance

Do you pay child maintenance?

YesNo

What do you spend on child maintenance? £

How often?

Weekly

Monthly

Dentist

Are you paying for regular dental costs?

YesNo

How much do you spend on regular dental costs? £

How often?

Weekly

Monthly

Do you have any other dental treatment?

YesNo

How much do you spend on other dental treatments? £

How often?

Weekly

Monthly

Please provide details

Debts - loans, credit cards, catalogues

Do you have a credit card?

YesNo

How much do you pay on credit cards? £

How often?

Weekly

Monthly

How much in total is owing on your credit card? £

Do you have any other credit cards?

YesNo

Do you have a debt to a catalogue

YesNo

How much do you pay on debt to a catalogue? £

How often?

Weekly

Monthly

How much in total is owing to the catalogue? £

Do you pay any other catalogues?

YesNo

Do you have a bank loan?

YesNo

What is the purpose of your loan?

How much do you pay on your loan? £

How often?

Weekly

Monthly

How much in total is owing to the bank? £

Do you have another bank loan?

YesNo

Do you have a family loan?

YesNo

How much do you pay on your family loan? £

How often?

Weekly

Monthly

How much in total is owing on your family loan (Amount in £'s)

Do you have a loan from a friend?

YesNo

How much do you pay on your friends loan? £

How often?

Weekly

Monthly

How much in total is owing on your loan from a friend (Amount in £'s)

Other debts

Do you owe money to any of the following?

Buy now/pay later loans	Council tax to another local authority
Gas or electric arrears for a previous address	Water or sewage charges for a previous address
Mobile phone arrears for a previous contract	TV streaming service arrears for a previous contract
None

Buy now/pay later loans

For your buy now/pay later loan, what was the loan for?

How much do you pay for your buy now/pay later loan (Amount in £'s)?

How often?

Weekly

Monthly

How much in total do you owe for your buy now/pay later loan (Amount in £'s)?

Council tax to another local authority

How much Council tax do you pay to another local authority?

How often?

Weekly

Monthly

How much in total is owing on your council tax to another authority (Amount in £'s)?

Water or sewage charges for a previous address

How much do you pay for water or sewage charges for a previous address

How often?

Weekly

Monthly

How much in total is owing on your water/sewage for a previous address (Amount in £'s)?

TV streaming service arrears for a previous address

How much do you pay for TV streaming service arrears for a previous address?

How often?

Weekly

Monthly

How much in total is owing on your TV streaming service for a previous address (Amount in £'s)?

Gas or electric arrears for a previous address

How much do you pay for gas or electric arrears for a previous address?

How often?

Weekly

Monthly

How much in total is owing on your gas/electric arrears for a previous address (Amount in £'s)?

Mobile phone arrears for a previous contract

How much do you pay for mobile phone arrears for a previous contract?

How often?

Weekly

Monthly

How much in total is owing on your mobile phone arrears for a previous contract (Amount in £'s)?

Are there any other regular payments you are making which you have not already declared?

YesNo

Please provide details

Income

Please tick all the types of income you are receiving

Attendance allowanceCarers allowanceChild tax creditsDisability living allowance - care component lower rateDisability living allowance - care component middle rateDisability living allowance - care component higher rateDisability living allowance - mobility component standard rateDisability living allowance - mobility component higher rateEarned incomeEmployment support allowanceIncome supportIndustrial injuries disablement benefitJobseekers allowanceMaternity allowancePersonal independence payment - standard ratePersonal independence payment - enhanced ratePersonal independence payment - mobility standardPersonal independence payment mobility enhancedPrivate pensionSelf-employed incomeState pensionStatutory sick payUniversal creditWorking tax credits

Child maintenance

Are you a single parent?

YesNo

Are you receiving child maintenance?

YesNo

How much do you receive? £

How often?

Weekly

Monthly

Have you applied to the child maintenance service?

YesNo

Are you receiving any income from the absent parent?

YesNo

How much do you receive? £

How often?

Weekly

Monthly

Income from non-dependants

A non-dependant is a person who lives in your property and is over the age of 18 and not in full time education and is therefore expected to contribute to the household bill.

Do any non-dependants live with you?

YesNo

How many?

Do they contribute to the household finances?

YesNo

How much, in total, do they contribute to the household finances finances?

Edit this text

How often?

Weekly

Monthly

Please state why they are not contributing to the household finances

Savings

Do you have any savings?

YesNo

How much do you have in savings? £

Is there any other income you receive that has not already been declared?

YesNo

Please provide details

Declaration

Is there any other information that you wish to provide regarding your financial circumstances which will enable the council to make a more informed assessment of your ability to pay the council tax due?

YesNo

Please provide details of the information you wish to provide regarding your financial circumstances.

Has anyone else helped you to complete this form?

YesNo

Do you give permission for the council to contact them regarding this application?

YesNo

Name of person who helped you complete this form

Relationship to you

Contact telephone number

Contact email address

Do you want to give permanent permission for this person to be contacted to discuss your council tax account in the future?

YesNo

What is the address of the person you are giving permanent permission to?

Confirmation

This is my claim for financial support. The decision whether or not to award a financial support payment will be based on the information I have supplied.

I have filled in the form to the best of my knowledge and declare that the information given is true.

I agree to the council making any necessary enquiries to confirm the information on this form or to obtain further information.

Full name

Date

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