Financial Assessment 
     Name                                                                   Address 
     DOB                                                                    NINO: 
     Telephone number:                                                      Email address 
     Income                                        weekly       monthly Expenditure                                    weekly       monthly
     Wages/Salary                                      £            £       Housing Costs                                  £             £
     Net Earned income (claimant)                                           Mortgage
                                                                             nd
     Net Earned income (partner)                                            2  Mortgage
     Benefits                                                               Rent
     Universal Credit                                                       Rent
     Housing Benefit                                                        Council Tax
     Council Tax Reduction                                                  Ground Rent/Service Charge
     Jobseekers Allowance                                                   Buildings Insurance
     Income Support                                                         Contents Insurance
     Employment & Support Allowance                                         Utilities
     Incapacity Benefit                                                     Water Rate/Sewerage
     Statutory Sick Pay                                                     Gas
     Maternity Pay                                                          Electricity
     Child benefit                                                          Other fuel
     Tax Credits                                                            Housekeeping
     Maintenance                                                            Food, General Items & Toiletries
     Bereavement Benefit                                                    Clothing (Adult)
     Carers Allowance                                                       Clothing (Children)
     Disability Living Allowance                                            Launderette
     Personal Independence Payments                                         Alcohol
     Employment & Support Allowance                                         Tobacco
     Pensions                                                               Pet Insurance
     State Retirement Pension                                               Children
     State Retirement Pension (Partner)                                     Childcare/ Afterschool Club
     Private Pension                                                        School Meals
     Private Pension (Partner)                                              Nappies/baby items
     Annuity                                                                Travel
     War Pension                                                            Public Transport
     Pension Credit Guarantee                                               Car Insurance
     Pension Credit Savings                                                 Car Tax
     Other Income                                                           Car Maintenance/MOT
     Non-dependants contribution                                            Petrol/Diesel
     Student Grant/Loan                                                 Car Loan
     Income from Lodgers/Property                                       Health
     Income from Capital Investments                                    Prescriptions                               13.00
     Other Income                                                       Prescription card yearly
     Other Income                                                       Household
     Other Income                                                                                                             2022.00
     TOTAL INCOME                                                       wifi
     Capital/Savings                                                    TV licence
     Bank/Building Society Account                                      Other Important Expenditure                                0.00
     Post Office Account                                                Maintenance/CSA Payments
     Premium Bonds                                                      Hire Purchase Agreements
     National Savings Certificates                                      Loans
     Shares, Stocks or Unit Trusts                                      Credit Card Debts
     Life Assurance/Endowments                                          Catalogues
     Tessas, PEPS or ISA’s                                              Court Fines
     Land or buildings other than your home                             Life Insurance/Pension
     Other Capital                                                      Telephone (Landline)
     TOTAL CAPITAL                                                      Telephone (Mobile)
                                                                                  Pay as you go or Contract  
                                                                        Other Expenses
                                                                        Pocket money
                                                                        Gifts (birthdays/Christmas)
                                                                        Gym
                                                                        Vet
                                                                        Other Expenses
                                                                        IVA or Debt recovery arrangement
     Have you approached
      family, friends, charities, or 
     hold any insurance policies for 
     assistance                               YES/NO                    TOTAL EXPENSES
      Are they able to assist you YES/NO
                                                                        Total Income 
                                                                        Total Expenses
     DECLARATION
     Please read this declaration carefully before you sign and date it.
     · I declare that the information I have provided is correct and agree with the financial assessment.
     · I understand that Bracknell Forest Council is under a duty to protect the public funds it administers and
     therefore agree that they may use the information I have provided on my application for the prevention
     and detection of fraud.
     · I understand that Bracknell Forest Council may also share this information with other bodies responsible
     for auditing or administering public funds.
   · I understand this information may be shared with advice agencies providing you support and advice.
   THIS IS A TRUE RECORD OF MY FINANCIAL SITUATION ON ......................................... (DATE)
   SIGNED: ................................................................ PRINT NAME: ......................................................