Please complete and return to the Corporate Collections section,
Hillingdon Borough Council Housing Benefit Overpayments,
PO Box 531, Sale, M33 0FQ.
Please note
As everybody has different income and expenditure, the ones listed are those
which are found to be the most common. Should you have any which are
additional (income and/or outgoings) to these, please provide details in the
space provided.
Breakdown of Income and Expenditure
Name:
Claim/Reference Number:
Address:
Date:
Home Telephone No:
Mobile Telephone No:
Email address:
Name of employer: _____________________________________________
Address of employer: ______________________________________________
_______________________________________________
Employers telephone number: ______________________________
Head Office Address:
______________________________
______________________________
______________________________
Works no / pay reference: ______________________________
Corporate Collections Section
Tel.0300 123 1384 Fax.01895 250361
Hillingdon Borough Council, Housing Benefit Overpayment
PO Box 531, Sale, M33 0FQ
www.hillingdon.gov.uk
email: [email protected]
Type of Income
Amount
State if
Weekly or
monthly
Earnings (inc self employed)
Partners earnings
Benefit received from DWP
(e.g. Job Seekers Allowance,
Disability Living Allowance)
State Retirement Pension
Partner’s State Retirement
Pension
Private Pension
Partner's Private Pension
Income from additional adults
residing in the property
(e.g. children over the age of
18)
Maintenance / Child Support
Child Benefit
Tax Credits
(not included in your earnings)
Any other income (please
provide details)
TOTAL
Comments
Type of Expense
Amount
State if
Weekly or
monthly
Housing
Rent
Mortgage
Service Charge(s)
Water
Council Tax
Gas
Electricity
Other household fuels
(please state)
Household Services
Buildings Insurance
Contents Insurance
Life Insurance
Telephone (landline)
Telephone (mobile)
Internet
TV Licence
Repairs, Service contracts
Appliance rentals
Child Support paid by you
Fines, CCJ’s etc
Child Care Costs
Private Pension
contributions
Medical/Accident
Insurance
Motoring/Travel
Vehicle finance
Spare/Servicing
Road Tax
Insurance
Breakdown cover
Fuel
Parking
Fares/Travel
Comments
For
Office
Use Only
Type of Expense
Amount
State if
Weekly or
monthly
Food/Housekeeping
Food, Toiletries, Cleaning
School Meals/Meals at
work
Pets (food & insurance)
Tobacco
Clothing & footwear
Misc. Goods &
Services
School trips/Activities
Hairdressing
Professional/Union fees
Laundry/Dry cleaning
Medicines/Prescriptions
Dentist
Opticians
Personal/Leisure
Newspapers, Magazines
Sports, Hobbies,
Entertainment
Children’s pocket money
Church/Charity
Sundries/Emergencies
Self Employed
Income Tax
National Insurance
Contributions
VAT
Other Costs
Comments
For
Office
Use Only
Type of Expense
Amount
Comments
For
Office
Use Only
State if
Weekly or
monthly
Other Debt
Repayments
Rent arrears
Mortgage arrears
Council Tax arrears
Credit/Store Card 1
Credit/Store Card 2
Credit/Store Card 3
Loan 1
Loan 2
Loan 3
TOTAL
Total Income used
Total Expenses used
Excess Income available
Please provide details of what you feel to be a realistic proposal for repayment. Although
this may not be what is agreed, it will be taken into consideration when looking at your
case.

Amount: £…………….

Frequency of payment e.g. monthly/weekly …………………

Date you can make your first repayment by ..….……………

Most convenient date for payments to be made (e.g. 1st of each month, every Friday)
………………………………………………………………

To make the agreed repayments you will automatically be provided with a Standing
Order mandate to complete and forward to your own bank/building society. If you
prefer to make repayments by payment vouchers, please state below.

I would prefer to make repayments by payment vouchers
I confirm, to the best of my knowledge the information I have provided is true and correct.
However, should my circumstances change I will notify you immediately.
Signed: …………………………………
Date: ……………………