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

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?

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

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

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 do they contribute to the household finances? £

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

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

TV licence	Broadband	TV streaming services	Gaming services
None

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

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