CITIZENS ADVICE JERSEY Name: ………………………………………………………………………………………………….. Date of birth:…………………………………………………………………………………………… Application: Single: □ Joint: □ ……………………………………………………………….. Partner’s name (if applicable): ………………………………………………………………………. Partner’s date of birth (if applicable): ………………………………………………………………. Address: ……………………………………………………………………………………………….. …………………………………………………………………………………………………………… Dependent children: Under 16: ……………. 16-18: ……………………………………………... Other dependents: …………………………………………………………………………………… Number in household: ……………………………………………………………………………….. Number of vehicles in household: …………………………………………………………………. □ Mortgage: □ Private tenant: □ Social tenant: □ ……..…….. Living with family: □ Other: □ ……………………………………………………………………. Employment: Full-time: □ Part-time: □ Unemployed: □ Self-employed: □ Retired: □ Partner: Full-time: □ Part-time: □ Unemployed: □ Self-employed: □ Retired: □ ……. Housing tenure: Owner: Please bring three months’ bank statements. If you are unable to attend your appointment, please telephone 871692. Appointment: ………………………………............................................................................... Adviser: ………………………………………………………………………………………… MONTHLY INCOME AND ASSETS *Please state the frequency of payments, e.g. weekly, monthly or annual. Caseworker Client Name INCOME Salary or Wages Client’s salary or wages (take home) Partner’s salary or wages (take home) Son’s/daughter’s contribution Other income Monthly Total Salary/Wages Amount £ £ £ £ £ *Frequency Benefits Jobseeker’s Allowance (Income-based) Jobseeker’s Allowance (Contribution-based) Income Support Incapacity Benefit/Statutory Sick Pay Short Term Incapacity Allowance Long Term Incapacity Allowance Other (e.g. Maternity Allowance) Monthly Total Benefits Amount £ £ £ £ £ £ £ £ *Frequency Pensions State pension(s) Private or work pension(s) Other pension(s) Monthly Total Pensions Amount £ £ £ £ *Frequency Other Income Maintenance or child support Boarders or lodgers Non-dependants’ contributions Student loans and grants Other Monthly Total Other Income Amount £ £ £ £ £ £ *Frequency Monthly Total Income £ ASSETS OR EQUITY House or Flat Total value of property(ies) Mortgage outstanding Secured loan(s) outstanding Total Equity £ Amount £ £ £ £ Other Assets Value of vehicle(s) (less HP outstanding) Savings Other assets Total Other Assets £ Amount £ £ £ £ Total Assets and Equity £ MONTHLY OUTGOINGS *Please state the frequency of payments, e.g. weekly, monthly or annual. Caseworker Client Name FIXED COSTS Home and Contents Rent Ground rent and service charges Mortgage Mortgage endowment Secured loans Parish rates Appliance and furniture rental (including HP) TV licence Other costs Monthly Total Home and Contents Amount £ £ £ £ £ £ £ £ £ £ *Frequency Utilities Gas Electricity Water Other (including coal, oil, calor gas) Other expenditure Monthly Total Utilities Amount £ £ £ £ £ £ *Frequency Care and Health Childcare Adult care Child maintenance Prescriptions and medicines Dentistry and opticians Other costs Monthly Total Care and Health Amount £ £ £ £ £ £ £ *Frequency Travel Public transport (work, school, shopping etc.) Hire Purchase or conditional sale vehicle Car Insurance Car Maintenance Breakdown or recovery Fuel and parking Other travel costs (including taxis) Monthly Total Travel Amount £ £ £ £ £ £ £ £ *Frequency School School uniform After school clubs and school trips Other costs Monthly Total School costs Amount £ £ £ £ *Frequency MONTHLY OUTGOINGS *Please state the frequency of payments, e.g. weekly, monthly or annual. Caseworker Client Name Pensions and Insurance Pension payments Life insurance Mortgage payment protection insurance Buildings and contents insurance Health insurance (medical, accident, dental) Other costs Monthly Total Pensions and Insurance Amount £ £ £ £ £ £ £ *Frequency Professional Costs Professional courses Union fees Professional fees Other Monthly Total Professional Costs Amount £ £ £ £ £ *Frequency Other Essential Costs Magistrate’s Court fines Amount £ £ £ £ £ *Frequency Monthly Total Other Essential Costs Monthly Total Fixed Outgoings £ FLEXIBLE COSTS Communications and Leisure Amount Home phone, internet, TV package, film £ subscriptions Mobile phone £ Hobbies, leisure, sport (e.g. socialising, eating £ out, clubs, leisure courses) Gifts (e.g. birthdays, festivals, charity) £ Pocket money £ Newspapers, magazines, stationery, postage £ Other costs