Council Tax special payment arrangement income & expenditure

"*" indicates required fields

1Using the form

2Declaration

3About you

4Your arrangement

5Your work

6Your income

7Your fixed outgoings

8Your flexible outgoings

9Your loans or debts

10Other info

Only complete this form if you have already submitted an offer of payment and have been asked to do so by the Council Tax team.

This form will ask you to provide

your details
your Council Tax account reference number
your National Insurance number
the amount you’re offering to pay and how often
the date you will be making your first payment.

Depending on your answers, this form may also ask you to provide:

if you work, information about your employer and employment
if you don’t work, information about any benefits you receive
details of your full income and outgoings
details of any loans or debts you have.

Please have this information ready as pages time-out after one hour.

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Privacy Statement

Dover District Council is a Data Controller under GDPR. In submitting this form we will collect and process your personal data. For information about your rights and how the Council uses your data, please view our Corporate and relevant service privacy notice which can be found on our Privacy page.

Declaration

Please check the box below to confirm that you have read, understand and agree to the following statements before completing this form:

I confirm the details I will give on this form will be correct and true.
I confirm that I will notify you of any relevant changes straight away.
I understand that if I give information that is false this could lead to a penalty or legal proceedings being taken against me.
I understand my data may be shared with other departments as permitted by law.

Declaration*

I understand and accept the above declaration

About you

Title (for example Mr, Mrs, Ms, Miss)*

First name*

Last name(s)*

Contact phone number*

Email address*

We will use your email address to send the receipt of your form, including the form reference number. This may include personal data. We will also use your email address to contact you about your Council Tax account.

Enter email address Confirm email address

Would you like to receive your Council Tax bills by email?*

You can receive your Council Tax bills by email rather than post. We will send all future Council Tax bills to the email address you have given above. If you change your email address you must let us know straight away. You can opt out of this at any time at dover.gov.uk/paperless

Yes

Council Tax account reference number*

National Insurance number*

About your address

Address*

Address line 1 Address line 2 Town or city Postcode

About your arrangement

How much are you offering to pay?*

Every*

Week

Two weeks

Four weeks

Month

When will you be making your first payment?*

Please make your first payment while awaiting confirmation of your arrangement

Day

Month

Year

About your work

Do you work?*

Yes

This field is hidden when viewing the form

About any benefits you claim

What benefit(s) do you claim?*

Disability Living Allowance (DLA)

Employment and Support Allowance

Housing Benefit

Income Support

Jobseeker’s Allowance

Pension Credit guarantee credit

Personal Independence Payment (PIP)

Universal Credit

None of the above

If you and your partner claim benefit jointly, which of you receives payment?

You

Your partner

Total amount of any other income you get

How often do you get paid this income?

This field is hidden when viewing the form

About your work

Name of employer*

Address of employer*

Employer's phone number*

Payroll number

Wages/salary (after tax and National Insurance contributions)*

How often are you paid?*

About your income

Please tell us about the money coming into the household, the amount and how often. This includes any income you and your partner receive and if any other adults living in the property contribute any money towards the household. If you get any income not listed, please use the ‘other income’ section at the bottom of this page.

Type of income*

Attendance Allowance

Carer’s Allowance

Child Benefit

Child Maintenance

Child Tax Credit

Disability Living Allowance

Employment and Support Allowance

Incapacity Benefit

Income Support

Jobseeker’s Allowance

Money paid to you by any other adults who live with you (not your partner)

Pension

Personal Independence Payment

Severe Disability Allowance

Wages or salary

Partners wages or salary

Working Tax Credit

Universal Credit

Other income

Amount – Attendance Allowance*

How often – Attendance Allowance*

Amount – Carer's Allowance*

How often – Carer's Allowance*

Amount – Child Benefit*

How often – Child Benefit*

Amount – Child Maintenance*

How often – Child Maintenance*

Amount – Child Tax Credit*

How often – Child Tax Credit*

Amount – Disability Living Allowance*

How often – Disability Living Allowance*

Amount – Employment and Support Allowance*

How often – Employment and Support Allowance*

Amount – Incapacity Benefit*

How often – Incapacity Benefit*

Amount – Income Support*

How often – Income Support*

Amount – Jobseeker's Allowance*

How often – Jobseeker's Allowance*

Amount – Money paid to you by any other adults who live with you (not your partner)*

How often – Money paid to you by any other adults who live with you (not your partner)*

Amount – Pension*

How often – Pension*

Amount – Personal Independence Payment*

How often – Personal Independence Payment*

Amount – Severe Disability Allowance*

How often – Severe Disability Allowance*

Amount – Wages or salary*

How often – Wages or salary*

Amount – Partners wages or salary*

How often – Partners wages or salary*

Amount – Working Tax Credit*

How often – Working Tax Credit*

Amount – Universal Credit*

How often – Universal Credit*

Please tell us about any other income, what it is, the amount and how often*

Enter the information and then click on the + sign to add another row for each type of other income.

Other income type

Amount £0.00

How often (weekly or monthly)

About your fixed outgoings

We need to know about all of your fixed outgoings, such as rent and bills. Please select all of your household outgoings and tell us the amount and how often. If you have any outgoings not listed, please use the other outgoings section at the bottom of this page.

Home and contents

Rent

Mortgage

Mortgage endowment

Council tax

TV licence

Secured loans

Help to Buy loan

Board

Ground rent and service charges

Household appliance hire purchase

Household appliance rental

Amount – rent*

How often – rent*

Amount – mortgage*

How often – mortgage*

Amount – mortgage endowment*

How often – mortgage endowment*

Amount – Council tax*

How often – Council tax*

Amount – TV licence*

How often – TV licence*

Amount – secured loans*

How often – secured loans*

Amount – help to Buy loan*

How often – help to Buy loan*

Amount – board*

How often – board*

Amount – ground rent and service charges*

How often – ground rent and service charges*

Amount – household appliance hire purchase*

How often – household appliance hire purchase*

Amount – household appliance rental*

How often – household appliance rental*

Transport and travel

Car insurance

Road tax

Fuel, parking and toll road charges

Breakdown cover

MOT and ongoing vehicle maintenance

Vehicle hire purchase

Vehicle lease

Public transport

Logbook loan

Amount – car insurance*

How often – car insurance*

Amount – road tax*

How often – road tax*

Amount – fuel, parking and toll road charges*

How often – fuel, parking and toll road charges*

Amount – breakdown cover*

How often – breakdown cover*

Amount – MOT and ongoing vehicle maintenance*

How often – MOT and ongoing vehicle maintenance*

Amount – vehicle hire purchase*

How often – vehicle hire purchase*

Amount – vehicle lease*

How often – vehicle lease*

Amount – public transport*

How often – public transport*

Amount – logbook loan*

How often – logbook loan*

Utilities

Dual fuel

Electricity

Gas

Water supply

Water waste

Other fuel

Amount – dual fuel*

How often – dual fuel*

Amount – electricity*

How often – electricity*

Amount – gas*

How often – gas*

Amount – water supply*

How often – water supply*

Amount – water waste*

How often – water waste*

Amount – other fuel*

How often – other fuel*

Care and health costs

Prescriptions and medicine

Dentistry

Opticians

Childcare

Child maintenance or child support

Adult care

Amount – prescriptions and medicine*

How often – prescriptions and medicine*

Amount – dentistry*

How often – dentistry*

Amount – opticians*

How often – opticians*

Amount – childcare*

How often – childcare*

Amount – child maintenance or child support*

How often – child maintenance or child support*

Amount – adult care*

How often – adult care*

Pension and insurances

Buildings and contents insurance

Life insurance

Mortgage payment protection insurance

Health insurance

Pension payment

Amount – buildings and contents insurance*

How often – buildings and contents insurance*

Amount – life insurance*

How often – life insurance*

Amount – mortgage payment protection insurance*

How often – mortgage payment protection insurance*

Amount – health insurance*

How often – health insurance*

Amount – pension payment*

How often – pension payment*

Professional costs

Professional courses

Professional fees

Union fees

Amount – professional courses*

How often – professional courses*

Amount – professional fees*

How often – professional fees*

Amount – union fees*

How often – union fees*

School costs

School uniform

After school clubs and school trips

Amount – school uniform*

How often – school uniform*

Amount – after school clubs and school trips*

How often – after school clubs and school trips*

Other essential costs

Criminal fine

Loan from family member or friend

Legal fees

Amount – criminal fine*

How often – criminal fine*

Amount – loan from family member or friend*

How often – loan from family member or friend*

Amount – legal fees*

How often – legal fees*

About your flexible outgoings

We need to know about all of your flexible outgoings, such as food and clothes. Please select all of your household outgoings and tell us the amount and how often. If you have any outgoings not listed, please use the other outgoings section at the bottom of this page.

Food and housekeeping

Alcohol

Groceries

Household repairs and maintenance

Laundry and dry cleaning

Meals at work

Nappies and baby items

School meals

Smoking products

Vet bills and pet insurance

Amount – alcohol*

How often – alcohol*

Amount – groceries*

How often – groceries*

Amount – household repairs and maintenance*

How often – household repairs and maintenance*

Amount – laundry and dry cleaning*

How often – laundry and dry cleaning*

Amount – meals at work*

How often – meals at work*

Amount – nappies and baby items*

How often – nappies and baby items*

Amount – school meals*

How often – school meals*

Amount – smoking products*

How often – smoking products*

Amount – vet bills and pet insurance*

How often – vet bills and pet insurance*

Communications and leisure

Home phone, internet and TV package

Mobile phone

Hobbies, leisure or sport

Gifts

Newspapers, magazines, stationery and postage

Pocket money

Charitable donation

Religious contribution

Amount – home phone, internet and TV package*

How often – home phone, internet and TV package*

Amount – mobile phone*

How often – mobile phone*

Amount – hobbies, leisure or sport*

How often – hobbies, leisure or sport*

Amount – gifts*

How often – gifts*

Amount – newspapers, magazines, stationery and postage*

How often – newspapers, magazines, stationery and postage*

Amount – pocket money*

How often – pocket money*

Amount – charitable donation*

How often – charitable donation*

Amount – religious contribution*

How often – religious contribution*

Personal costs

Clothing and footwear

Toiletries

Hairdressing

Amount – clothing and footwear*

How often – clothing and footwear*

Amount – toiletries*

How often – toiletries*

Amount – hairdressing*

How often – hairdressing*

Any other outgoing costs

Please tell us about any other outgoing costs, what they are, the amount and how often

Enter the information and then click on the + sign to add another row for each other outgoing cost.

Type of outgoing cost

Amount £0.00

How often (weekly or monthly)

Do you have any outstanding loans or debts (including rent arrears)?*

Yes

About your loans and debts

Please tell us about your loans and debts including the monthly amount payable and the total amount outstanding or owed.

Type of loan or debt

Catalogue(s)

Credit card 1

Credit card 2

Credit card 3

Court fines

Loan 1

Loan 2

Loan 3

Loans from friends/family

Store card(s)

Utility (for example gas, water, electricity) arrears

Rent arrears

Other loans or debts

Amount payable monthly – Catalogue(s)*