Libranox Mediation Centre | Financial Statement

Thank you for remaining engaged with our Mediation Centre

Please complete the below, Financial Statement, detailing your household income and expenditure

NB:You must include income for all adults living at your property

Please keep in mind that non-essential spending must be at a minimum otherwise your Local Authority / Enforcement Agency may disregard the entry. This will demonstrate willingness to resolve this priority debt in the first instance.

Non-essential spending areas are; Loans, Credit Cards, Mobile Phones, Cable/Satellite TV, Pocket Money, Hobbies etc…

Once you have completed the statement, hit “submit” – and once we have received this, we will check through it before sending it to your Local Authority and Enforcement Agency for their perusal and decision.

Online Application for Libranox Mediation Centre

Your Details

*Firstname

*Surname

*Contact Number

*E-mail Address

Income

Salary and Benefit Payments for all adults living with you. This is to be entered as a monthly figure

*Your Salary (£)

*Adult 2 Salary (£)

Other Salary Based Income (£)i.e. a second job

Child Benefit (£)

Disability Living Allowance (£)

Personal Independence Payment (PIP) (£)

Child Tax Credit (£)

Working Tax Credit (£)

Housing Benefit (£)

Receives Council Tax Support ?

Yes     No    

Universal Credit (£)

Jobseekers Allowance (£)

Income Support (£)

Maternity Allowance (£)

Statutory Maternity Pay (£)

Carer's Allowance (£)

Statutory Sick Pay (£)

Bereavement Benefit (£)

Employment Support Allowance (£)

Your Pension (£)

Adult 2 Pension

Other Pension (£)

Lodger Income (£)

Student Loan / Grant (£)

Expenditure

Please be as honest as possible in this section.

Priority Expenditure

*Rent / Mortgage (£)

*Council Tax (£)

Secured Loan (£)

Gas (£)

*Electricity (£)

*Water (£)

Vehicle HP (£)

TV Licence (£)

Child Maintenance (£)

Childcare (£)

Transport Expenditure

Public Transport (£)

Vehicle Insurance (£)

Vehicle Tax (£)

MOT Costs (£)

Breakdown Cover (£)

Parking / Tolls (£)

Fuel (£)

Household Expenditure

*General Shopping (£)Food, Cleaning Products, Toiletries etc...

Laundry / Dry Cleaning (£)

Clothing / Footwear (£)

Nappies / Baby Items (£)

Pet Food (£)

Health (Prescriptions, Dentist, Opticians etc) (£)

House Rapairs (£)

Hairdressing (£)

TV Package (£)

White Goods HP/Rental (£)

School Meals (£)

Meals at Work (£)

Communications Expenditure

Landline Phone (£)

Mobile Phone (£)

Internet (£)

Other Expenditure

Pocket Money (£)

School Trips / Clubs (£)

Hobbies (£)Gym etc...

Pet Insurance (£)

Life Insurance (£)

Home Insurance (£)

Union Fees (£)

Proposal of Payment

*Amount Offered (£)

*Frequency

Weekly     Fortnightly     Monthly    

*Date you can make first payment

Fields with (*) are compulsory.