Revenues and Benefits Service
Wakefield One, PO Box 700
Burton Street, Wakefield WF1 2EB
Tel: 0345 8 504 504
Self Employed Earner – Certificate of earnings
If you receive a wage or hourly rate from a company you are classed as employed and do not need to
complete this form.
If you have only just started your business and have not been trading for very long then you can use an
estimate for what you think your income and expenditure will be / has been for the first 13 weeks of your
trading. After 13 weeks we will contact you to review your Housing Benefit claim.
Section 1: About you
Name
National Insurance
Number
Address:
(home)
Post Code
Telephone number
Email address
Section 2: About your business
Business name
Business address
Please describe the nature of your business
Are you a self-employed child
minder?
Yes / No
OFSTED registration number
When did you start your business?
DD/MM/YY
When did your current financial year start?
DD/MM/YY
How many hours per week do you work in your business?
Is your business a partnership?
Yes / No
Is your husband/wife/civil partner also a partner
of this business?
What share of the profit / loss is yours?
Yes / No
What is their share of the
profit?
Do you have prepared accounts (audited or not) for the last
financial year?
Yes / No
Are they a reflection of your current income?
Yes / No
If not a reflection of your current income, please say why they are not below:
If you have a set of accounts for the last financial year and these reflect your current earnings, please go to
Section 5 of this form and send us a copy of the accounts
If you don’t have any accounts, you have not been trading for more than 13 weeks or your trading circumstances
have recently changed go to Section 3 using your best estimate where applicable
Section 3: Income & Expenditure
These figures should show your total sales BEFORE any expenses are deducted
DD/MM/YY
The figures below are for the period
Total Sales/Takings/Income
£
plus Payments or grants received to set up your business
+£
minus Cost of purchases
- £
Total Income (Gross profit)
£
to
DD/MM/YY
Section 4: Expenses
These are the costs for the period of time show in Section 3. You must only include amounts which relate solely
to the business e.g. telephone – if calls are made, you must apportion the total cost in accordance with the
amount of private use and enter the amount for business use only
Business only
Rent (business premises/proportion of home rent for business)
Mortgage interest
Business Rates
Water rates
Heating and Lighting
Cleaning
Telephone
Business Insurance (inc. Public Liability insurance)
Property Insurance
Bank charges
Interest payments on any business loans
Repair / Replacement of business assets (excluding motoring)
- Was this covered by insurance?
Leasing charges
£
£
£
£
£
£
£
£
£
£
£
£
Yes / No
£
Motoring expenses
Fuel
Lease
Insurance
Road Tax
Repairs
£
£
£
£
£
Other expenses
Accountant’s charges
Advertising
Printing / Stationery / Postage
Bank charges
Drawings of cash/goods belonging to business for own use
£
£
£
£
£
Wages paid to self
Wages paid to marital partner
Wages paid to others
£
£
£
Wages paid to others
Wages paid to others
Name
Address
Name
Address
Name
Address
£
£
Other (please state)
Other (please state)
Other (please state)
£
£
£
National insurance
Pension contributions (paid to private pension scheme)
Income / PAYE Tax
£
£
£
Per week
Per week
Per year
Are your trading figures for the next 6 months likely to be similar to those given?
Yes / No
If no, please explain why they may be different below:
Please supply proof of the income and expenses entered.
Section 5: What to do next.
Completed forms can be returned:



In person at Wakefield One Customer Access Point, Burton Street, Wakefield MDC or at your local
Wakefield and District Housing Service Access Point.
By email to [email protected]
By post to Wakefield Council Revenues and Benefits Service, Wakefield One, PO Box 700, Burton
Street, Wakefield WF1 2EB. Please ensure you attach the correct postage.
Please note that we do not advise sending valuable documents through the post. If you need to
enclose any additional sheets, please put your name at the top of each additional page.
Section 6: Declaration
This information is in support of my claim for Housing/Council Tax Support
•
•
•
•
I declare that the information given on this form is true and complete to the best of my
knowledge.
I will inform the Revenues and Benefits Department immediately should my/our income or
circumstances change.
I understand that failure to declare a change in circumstances is a criminal offence and I may be
prosecuted (Theft Act 1968 or Social Security Acts or Fraud Act 2006).
I understand that a delay in telling you of any change in circumstances may mean that I have to
repay any benefit which has been overpaid.
Name: (please print)
Signature:
Date: