Income £ per month Expenditure £ per month

Housing Benefit Entitlement Rent

Wages Council Tax
Income Support Gas, Electric & Water
JSA Other
ESA (component) Other
CHILD BENEFIT Mobile & Landline
Child Tax Food shopping
Working Tax Credit Clothing
Carer's Allowance Rail Fare
Student Loan Loans
DLA Mobility Children's extra curriculum
DLA Middle Component TV Licence & Satellite

INCOME AND
Nursery

Total 0 Total 0
EXPENDITURE:

Name:

N.I number:

Date of birth:

Contact number:

Nationality:

DECLARATION:

I/We declare that the information given on this form is true and correct. I/We will notify the
Council of any changes in my circumstances.

Signed: __________________________________ Dated: ____________________