Income and Expenditure Form

You are receiving this form because you’ve indicated that you are currently unable to settle your debt in its entirety.

The Income and Expenditure Form serves as a tool for our client to evaluate the proposals you’ve submitted. It allows them to make a well-informed decision regarding whether to accept the repayment plan you’ve put forward.

Important Details:

• Complete the form with as much detail as possible.
• Fill out the form on a monthly basis, reflecting both your income and expenses.
• If you prefer to include only your personal income in the financial statement rather than the entire household income, focus on the bills you cover individually or your specific contribution to jointly paid bills. (You can indicate whether it is a sole or joint breakdown in section 3).
• Please be aware that we may request evidence of your income and expenditures.
• To calculate the average per calendar month for a weekly income/spend, use this formula. (weekly payment amount X (times by) 52 / (divided by) 12).

FINANCIAL STATEMENT FORM

Step 1 of 7 - Reference Number:

14%

Reference Number

First Name:

First Name:

Current Address:

Current Address:

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands

Date of Birth:

Date of Birth

Phone Numbers:

Home

Mobile

Work

Other

Email Address:

Email Address:

Housing Status:

Housing Status:

Owner

Living with Parents

Rent (Private)

Tenant (Social)

Other (Specify)

No. Dependant children:

No. Other dependants:

No. In household:

No. Of vehicles in household:

Employment Status:

Select Employment Status

Employed Full-time (go to Section 1)Employed Part-time (go to Section 1)Unemployed (go to Section 3)Self-employed (go to Section 2)Retired (go to Section 3)Student (go to Section 3)Carer (go to Section 3)

Other (Specify)

Employment Details

Your Job Title:

Your Job Title:

Work Address:

Work Address:

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands

Employee Name:

Employee Name:

First

What is your gross pay before tax?

Gross Pay Number:

Gross Pay Per:

Do you receive working tax credit?

Work tax credit

Yes

No

Work tax credit Number

How much?

Work tax credit per

How much?

How often are you paid?

Paid

Weekly

Monthly

Other

Do you have any other jobs?

Other jobs?

Yes

No

If yes, give full details below.

Self Employed

How long have you been self employed?

How long have you been self employed?

What is the nature of your business?

What is the nature of your business?

Do you receive working tax credit?

Do you receive working tax credit?

Yes

No

Other

If yes, what is the address?

What is your annual turn over?

What is your annual turn over?

What amount of profit did the business make over the last year?

What amount of profit did the business make over the last year?

How much do you draw from the business?

How much do you draw from the business? £

How much do you draw from the business? per

Your Income
(Please indicate if the below break down is your sole income or joint with your household/partner.)

Your Income

Just Me

Joint

Your Net Wages

Amount: Your Net Wages

Amount

Notes: Your Net Wages

Notes

Private pension

Amount: Private Pension

Notes: Private Pension

Income Support

Amount: Income Support

Notes: Income Support

Jobseeker’s Allowance

Amount: Jobseeker's Allowance

Notes: Jobseeker's Allowance

Child Benefit

Amount: Child Benefit

Notes: Child Benefit

Working Tax Credit

Amount: Working Tax Credit

Notes: Working Tax Credit

Child Tax Credit

Amount: Child Tax Credit

Notes: Child Tax Credit

Incapacity Benefit

Amount: Incapacity Benefit

Notes: Incapacity Benefit

Pension Credit

Amount: Pension Credit

Notes: Pension Credit

Carers’ Allowance

Amount: Carers' Allowance

Notes: Carers' Allowance

Money from anyone who lives with you (I.e. Lodger)

Amount: Money from anyone who lives with you

Notes: Money from anyone who lives with you

Housing Benefit

Amount: Housing Benefit

Notes: Housing Benefit

Council Tax Benefit

Amount: Council Tax Benefit

Notes: Council Tax Benefit

Other State benefits

Amount: Other State Benefits

Notes: Other State Benefits

Other Income

Amount: Other Income

Notes: Other Income

Total Income

Total Income: Section 3

Your Expenditure
* (If your income above was your sole income, please ensure you only provide details of your sole contribution for expenditure below. Otherwise, please use joint)

Your Income

Just Me

Joint

Housing

Mortgage payments

Amount: Mortgage payments

Amount

Notes: Mortgage payments

Notes

Rent

Amount: Rent

Notes: Rent

Council Tax

Amount: Council Tax

Notes: Council Tax

Buildings and contents insurance

Amount: Buildings and contents insurance

Notes: Buildings and contents insurance

Secured Loans

Amount: Secured Loans

Notes: Secured Loans

Charging orders

Amount: Changing Orders

Notes: Changing Orders

Utilities

Water

Amount: Water

Notes: Water

Electricity

Amount: Electricity

Notes: Electricity

Gas

Amount: Gas

Notes: Gas

TV Licence

Amount: TV Licence

Notes: TV Licence

Cable Television

Amount: Cable Television

Notes: Cable Television

Phone (Landline & Mobile)

Amount: Phone

Notes: Phone

Vehicles/ travel

Road Tax

Amount: Road Tax

Notes: Road Tax

Fuel/ Parking

Amount: Fuel/Parking

Notes: Fuel/Parking

Vehicle Insurance

Amount: Vehicle Insurance

Notes: Vehicle Insurance

Vehicle Finance

Amount: Vehicle Finance

Notes: Vehicle Finance

Travelling expenses

Amount: Travelling Expenses

Notes: Travelling Expenses

Living/ misc

Housekeeping (incl. groceries and toiletries)

Amount: Housekeeping

Notes: Housekeeping

Prescription / dentist costs

Amount: Prescriptions/dentist costs

Notes: Prescriptions/dentist costs

Childcare

Amount: Childcare

Notes: Childcare

Child Maintenance

Amount: Child Maintenance

Notes: Child Maintenance

School Meals/ meals at work

Amount: School/Work Meals

Notes: School/Work Meals

Clothing and shoes

Amount: Clothing and Shoes

Notes: Clothing and Shoes

Pet costs (E.g. food/ insurance)

Amount: Pet Costs

Notes: Pet Costs

Life insurance/ Pension

Amount: Life insurance/Pension

Notes: Life insurance/Pension

Tobacco

Amount: Tobacco

Notes: Tobacco

Newspaper/Magazines

Amount: Newspaper/Magazines

Notes: Newspaper/Magazines

Other (specify)

Amount: Other

Notes: Other

Other (specify)

Amount: Other

Notes: Other

Other (specify)

Amount: Other

Notes: Other

Other (specify)

Amount: Other

Notes: Other

Total expenses

Total Expenses: Section 4

Total income

Total Income: Section 4

Minus total expenses

Minus Total Expenses: Section 4

Balance

Number

DEBTS
Please indicate any debts you owe to creditors

Creditor

Amount Owed

Amount Monthly repayments

Do you have a CCJ against you?

Yes

No

Creditor 2

Amount Owed 2

Amount Monthly repayments 2

Do you have a CCJ against you for this? 2

Yes

No

Creditor 3

Amount Owed 3

Amount Monthly repayments 3

Do you have a CCJ against you for this? 3

Yes

No

Creditor 4

Amount Owed 4

Amount Monthly repayments 4

Do you have a CCJ against you for this? 4

Yes

No

Creditor 5

Amount Owed 5

Amount Monthly repayments 5

Do you have a CCJ against you for this? 5

Yes

No

Totals:

Owed: Section 5

Monthly Repayments: Section 5

Additional information

(e.g. reasons for debt due to our client, your personal circumstances etc.)

Your offer of repayment

I will pay in full on

I will pay in full on

Pay in full on Date

I can and will pay by instalments of

I can and will pay by instalments of

I can and will pay by instalments of

Per week / month

per week

per month

Declaration

• The information I have given is true and complete to the best of my knowledge.
• I understand that if I give information that is incorrect or incomplete, you may take action against me. This may include court action.
• I understand that you may check the information I have given on this form.
• I know that I must tell you if my circumstances change after I make this claim.

Untitled(Required)

I confirm the declaration

Full Name(Required)

First Last

Dated(Required)

Email: email@acclaim.law

Acclaim Credit Management & Recovery
8-16 Dock Street
Leeds
West Yorkshire
LS10 1LX