FINANCIAL ASSESSMENT FORM

MONTHLY INCOME AND EXPENDITURE

Income Monthly Total
Wages or Salary
Other Income
Benefits Income
Pension Income
TOTAL (A) £  0
Expenditure Monthly Total
Rent
Ground rent or service charge
Mortgage
Mortgage endowment
Other secured loans
Council tax (rates in NI)
Building and contents insurance
Pension and life insurance
Gas
Electric
Water
Other utilities
TV licence
Magistrates or Sheriff court fines
Maintenance or child support
Hire purchase or conditional sale
Childcare costs
Adult care costs
Phone
Travel
Housekeeping
Other expenditure
TOTAL (B) £  0

PRIORITY AND NON-PRIORITY DEBTS

Priority debts Arrears only Total owed Monthly repayment
Rent
Mortgage
Other secured loans
Magistrate/Sheriff court fines
Maintenance or child support
Gas
Electric
Water
Other fuel
Hire purchase or conditional sale
TOTAL (C) £  0 £  0
Non-priority debts Arrears only Total owed Monthly repayment
1
2
3
4
5
6
7
8
9
10
11
12
13
TOTAL (D) £  0 £  0
TOTAL AVAILABLE FOR CREDITORS (BOX A - BOX B)
TOTAL MONTHLY DEBT REPAYMENTS (BOX C + BOX D)
Offer of £payment per month/week/fortnight (please specify)
Dated
I confirm the Financial Assessment Form is a true and accurate record of my financial position

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