Online personal financial statement 1 Personal details 2 Your household 3 Income 4 Outgoings 5 Review 6 Summary 7 Submit Progress 14% Name Your address Address 1 Address 2 City Postcode Does the debt relate to different address Yes No Address debt is owed for Address 1 Address 2 City Postcode Email Do you wish to manage your council tax online? Yes No Telephone Mobile Council Tax Reference Are you employed? Yes No Are you self employed? Yes No Employer name Employer Address 1 Employer Address 2 Employer City Employer Postcode Payroll number Do you receive benefits? Yes No NI Number Type of benefit received Universal Credit ESA Disability Living Allowance Child/One Parent Benefit Child Tax Credit Working Tax Credit Council Tax Support Housing Support Income Support Carers Allowance Maternity Allowance Jobseekers Allowance Statutory Maternity Pay Statutory Sick Pay Bereavement Benefit Bereavement Benefit Do you receive a pension? Yes No Are you a student? Yes No Number of adults Children under 18 You should include in your declaration of income the contribution made by all resident adults towards the household expenses. Please select the period for which you would like to specify you incoming and outgoings Monthly Weekly Your take home pay £ Capital £ Student loan £ Student grant or Bursary £ State Retirement Pension £ Pension Credit £ Occupational or Private Pension £ Retirement Allowance £ Other income Click + to add an income type + Please enter your outgoings for each month. Mortgage / Rent £ Gas £ Electricity £ Water £ Council Tax £ Food £ TV licence £ Phone £ Travel £ Clothing £ Loans £ Credit cards £ Catalogues £ Savings £ Mobile Phone £ Mobile Phone £ Broadband £ Satellite/Cable/Digital Service £ Home Insurance £ Life Assurance £ Car Insurance £ Pet Insurance £ Petrol Diesel £ Petrol Diesel £ Nursery Fees £ Other expenditure Click + to add an expenditure type. + Are there any circumstances you wish to make us aware of? Are you willing to pay by direct debit? Yes No We can refer you to our partner agency, Liverpool Citizen Advice Partnership (LCAP) who can provide you with support with managing your money and paying your bills. Click yes if you would like us to refer you to LCAP Yes No Make us an offer you believe to be affordable £ PreviousNextFinish