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Personal details. Employment details. Are you self-employed? No Yes. No Yes. No Yes. No Yes

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Academic year: 2022

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Personal details

Full name

Date of birth DD MM YYYY

National Insurance number

Home address

Home phone number

Business address

Business phone number

Mobile number

Marital status

Single Married Separated

Divorced Widowed

Do you have dependant adults or children?

No Yes

If ‘Yes’ to having dependant adults or children, give details including ages of children

I give you authority to speak to:

Accountant Solicitor Other (give name and address) Contact details

Employment details

Are you self-employed?

No Yes

If ‘Yes’ your current trade

Do you have CIS4 Registration card?

No Yes

Are you or have you ever been VAT registered?

No Yes

If ‘Yes’, what is your VAT Registration number?

Date VAT returns are due

VAT/Excise outstanding

Date of deregistration (if applicable) DD MM YYYY

s

Address

Postcode Address

Postcode

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Employment details continued

Are you in PAYE employment?

No Yes

Job title

PAYE reference number

Name of employer

Address

Phone number

Are you unemployed?

No Yes

Are you claiming benefits?

No Yes

If ‘Yes’ at which office

Date of first claim DD MM YYYY

Claim reference number

I authorise the Department for Work and Pensions to release details of my claim

No Yes

Home details

Do you own your own home?

No Yes

If you have answered ‘Yes’ to the previous question, are you the:

Sole owner Joint owner

Date purchased DD MM YYYY

Mortgage at purchase

Current mortgage

Cost of purchase

Current value

Other charges related to your purchase

Type of mortgage/charges (interest only, repayment)

Name of lender

Rented property

Do you live in a rented accommodation?

No Yes

If ‘Yes’ what is the name of the landlord?

Address of the landlord

Is the property:

Furnished Unfurnished

Long lease Short lease Address

Postcode

Address

Postcode

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Assets and savings

If you answer ‘Yes’ to any of the following questions give full details and the estimated values. Continue on page 4 if you need more space.

Do you have any life/endowment insurance policies?

No Yes

If ‘Yes’ give details

Have you asked a bank or building society for a loan to settle your debts?

No Yes

Do you own or rent out any other property(s) including overseas property(s)?

No Yes

Give details including value and mortgage

Do you have any bank or building society accounts?

No Yes

Bank or building society name

Account number

Sort code

Balance in your account

Continue on page 4 if you have more than 1 account Do you own any motor vehicles?

No Yes

Make and model of motor vehicle

Registration number

Value at purchase

Date of purchase DD MM YYYY

Date of final HP payment DD MM YYYY

Do you have any Savings Certificates/Premium Bonds/stocks/shares/ISAs?

No Yes

If ‘Yes’ give details

Do you have any other assets? For example, jewellery, paintings, antiques, money owed to you etc

No Yes

If ‘Yes’ give details

Income and expenditure

Average monthly take home pay

Your partner’s income after tax

Contribution by children or others living with you

Rental income if any

Income from investments

Benefits

Other sources of income for example, pensions

Total monthly income after tax (A) 0 0

£ •

− −

0 0

£ •

0 0

£ •

0 0

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0 0

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0 0

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0 0

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0 0

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Monthly expenditure

Mortgage/rent

Life Assurance, endowment policies, home and building contents insurance

Council Tax

Water, gas, electricity, telephone

Travel to work

Petrol, car insurance and maintenance

Pension payments

Food and clothing

Satellite TV or digital TV package and TV Licence

VAT payments

Amount put aside to pay future tax liabilities

Total monthly payment of other debts for example, loans, hire purchase, credit cards

Other

Total monthly payment (B)

Net monthly disposable income (A minus B)

Details of creditors

Creditors name Outstanding debt Monthly payment Final payment

date

£ £

£ £

£ £

Total £ £

Other considerations

If there is anything else you want us to consider, give the details below. You should also state whether any of the details provided are about to change in the near future. If more space is needed, attach a separate sheet.

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Proposals for payment

I offer to pay

Per month until my debt of

is cleared.

I enclose a payment of

I understand that consideration of my offer will be conditional upon:

1. submitting any overdue tax returns immediately and sending future tax returns on time

2. paying by direct debit. Your completed direct debit mandate must be enclosed with this form. Where you have a preference, state on which date you would like your direct debit payment collected

Date of direct debit payment collection DD MM YYYY

I understand that my future tax liabilities must be paid as it becomes due and interest will continue to be added to my debt until it’s paid in full.

I understand that completing this form and/or the direct debit mandate doesn’t guarantee my offer is acceptable

I understand that any incomplete or inaccurate information will result in my offer being refused

I understand that HM Revenue and Customs may check the details I have provided

Declaration

I declare the information I have given is true and complete

Signature

Date DD MM YYYY 0 0

£ •

0 0

£ •

0 0

£ •

References

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