Housing Benefit and Council Tax Benefit
Self Employed Form
In order to work out your Housing Benefit and Council Tax Reduction we need to make an
estimate of your income from your self employed business.
Please complete this form as fully and accurately as possible using the guidance notes at
the end of the form.
You must provide;
- Your latest profit and loss sheet drawn up by an accountant
- original documents to prove your other income and expenses
If you are a Mini Cab driver, a Taxi Driver, or a Chauffeur you will also need to provide:
- evidence of your PCO licence
- your last two most recent MOT certificates
- proof of your insurance
- your Uber statements (if you receive your jobs via the Uber app)
- your fare logs
Claim number
Your name
Your address
Telephone Number
Email address
Business Name
Business Address
Business Type
Date your business
started
Number of hours you
work per week
Revenue & Benefits Service
Tel. 0300 123 1384 Fax: 01895 250361
LB Hillingdon Revenues & Benefits service
PO Box 531, Sale, M33 0FQ
www.hillingdon.gov.uk
Email: [email protected]
Are you registered for
VAT?
See note 1 on page 6
Are there any business
partners?
See note 1 on page 6
Do you use part of your
home for business?
See note 1 on page 6
Do you use your phone
for business purposes, if
yes, please state the
percentage use.
Do you pay into a
pension scheme?
See note 2 on page 6
How would you
describe the type of
work?
How do you get jobs?
See note 3 on page 6
Do you have a second
car?
See note 4 on page 6
What percentage of
the time do you use
your work car for
personal use?
You must provide us with details of your income and expenses for your business.
You need to specify a period covered by these figures.
What period is covered by this form?
See note 5 on page 6
From
To
2
Income
Income
See note 6 on page 6
Opening Stock
See note 7 on page 6
Closing Stock
See note 7 on page 6
Purchases
See note 7 on page 6
Expenses
Type of expense
Frequency or
Period
Amount
Percentage
business use
See note 8 on page 6
See note 9 on page 6
See note 10 on page 6
See note 11 on page 6
Accountancy
Advertising
Base / radio rent
(mini cab driver)
Business Insurance
Business premises rates
Business premises rent
Cleaning
Car / van insurance
Car / van Tax
Car / van repairs
Fuel
PCO licence (mini cab driver)
Printing, Stationary, Postage
Telephone
3
If you are a Mini Cab driver, a Taxi Driver, or a Chauffeur please answer the
following:
What make of car do you drive for
work?
Registration Number
Engine size
Current mileage on the clock
How many miles per litre of fuel do
you obtain?
What type of fuel do you use (petrol or
diesel)?
How much do you charge per mile?
What is your minimum fare?
Do you receive your jobs via the Uber
app?
Do you have a phone provided by
Uber?
Do you receive your jobs via the Taxi
Code app?
4
Declaration
Please read the declaration carefully and then sign and date below
I understand the following:
 If I give answers that are wrong or if I leave information out, you may take action
against me.
 If I provide supporting documents that are incorrect, altered or misleading in any way,
you may take action against me.
 You will use the information I have provided to process my claim for Housing Benefit or
Council Tax Benefit or both. You may check any of the information with other sources
within the council, rent offices and other councils or with other sources.
 You may use any information I have provided in connection with this and any other
claim for Social Security benefits that I have made or may make.
 You may give the information to other government organisations, if the law allows this.
 Any information that I give on this form, or in connection with this form, may be
exchanged with other bodies, in accordance with the law, for the prevention of fraud
and abuse.
 I know I must let the council know about any changes in circumstances, which might
affect my claim.
I declare the information I have given on this form is correct and complete.
Signature of self
employed person
Print Name
Date
If you have completed this form for someone else, you must also sign to confirm the
following;
I completed the form with answers that were supplied by the self employed person named
at the top of this form. When I completed the form I read the answers back to them and
they confirmed they were correct.
Signature of
person who
completed the
form
Print Name
Relationship to
self employed
person
Date
5
Notes on how to complete this form
1
2
If yes, we will contact you about this
You will need to provide evidence of this. We will disregard 50% of your pension
contributions from your income.
3
Some drivers wait at a ‘base’ for jobs, and then always return to base after a job,
some gets job via radio or mobile phone whilst they are out, others work on advance
bookings. In these two questions please explain what type of work you do and how
you get the jobs.
4
If you do have a second car, please provide evidence of this, for example, the log
book or recent MOT certificate.
5
If you have been trading for over a year and already have accounts for that year,
your period could be the previous financial year.
If you have been trading for less than a year the best period would probably be from
the start of your business up to the current date
If you have only just very recently started your business, you can give future dates
and provide estimates of what you expect your income and expenditure to be.
If something has changed significantly, for example you used to work full time but
now only work part-time; the period can be from the date the change happened up to
current date.
6
The period cannot be more than one year.
Income means all the money you have coming into your business before you have
deducted any outgoings at all.
7
You only need to complete the sections about stock if you buy items to sell on for
profit. Opening stock means the value of any stock you already had on the start date
of the period (see note 3). Closing stock means the value of any stock you had left
at the end of the period. Purchases are how much you spent on items to sell on (but
not on other expenses).
8
In this column, enter the different types of expenses. Some common expenses are
already listed; if you have other expenses use the blank lines and write the type of
expense in the first column.
9
In this column write either;
 the frequency of the expenses, for example, if you pay £20 per month for a
phone contract, write “monthly”, or if you have an annual cost for accountancy,
write “annual”

10
11
or, write the period the expenses cover (see note 3), so if you have already
specified above a 13 week period, for example from 7 November 2011 to
5 February 2012, you can write that in this column.
In this column write the amount you spent on this expense.
Write down what percentage of the amount was spent purely for business for use.
For example, if you have a mobile phone contract, but you also use the phone 40%
of the time for personal use, write 60% in this column
6