Current Your income and expenditure Complete *Name *Phone Number *Email Address *Address Address Address 2 City/Town Postcode *This support is only available for our customers. Please tick to confirm that you are a LiveWest customer. *Do you need support with any of the following? managing my rent account accessing benefits my finances or debts accessing support around a disability or vulnerability accessing general information or other community support housing, ASB or Neighbourhood issues energy advice accessing external grants for household items other *Please provide details of the support needs which you have selected above. *If your application is successful please tick to confirm that you agree for LiveWest to share your details with a 3rd party for the processing of payment or vouchers. Your income and expenditure This section of the application looks at your monthly income and expenditure. Please answer as accurately as possible, completing all sections of the form. If a particular expense or income source does not apply to you, please enter '0' as the value. Income *Your net salary/wage (monthly) *Your partner's net salary/wage (monthly) *JSA/Universal Credit *ESA *Child tax credit *Working tax credit *Carers allowance *DLA/AA/PIP *Child benefit *Maintenance/CSA *From non-dependants *Pension *Housing benefit *Total household income (monthly) Expenditure *Rent *Mortgage *Council tax *Life assurance *Buildings/contents insurance *Electricity *Gas *Water and sewerage *Mobile telephone *Television/internet/broadband package *TV licence *Maintenance/CSA *Housekeeping/groceries *Toiletries/cleaning *Nappies/baby needs *Nursery/childcare *Children's activities/pocket money *School meals/milk/outings *Clothing/footwear *Haircuts *Leisure/outings *Religious festivals/birthdays *Dentists/prescriptions/opticians *Pet food/vet bills *Car HP payment *Road tax *Car insurance *Tyres/MOT/repairs/servicing *AA/RAC/equivalent *Fuel *Bus/taxi/train fares *Emergencies/savings *Takeaways/snacks *Cigarettes/tobacco *Alcohol *Other *Total monthly expenditure Priority debts *Rent/Service Charge Arrears (£) *Credit Cards/Loans/HP (£) *Council Tax Arrears (£) *Utility Arrears: Water/Gas/Electric (£) *TV Licence Arrears (£) *HB overpayments (£) *Any Other Debts/Fines (£) *Total priority debts - amount of arrears you owe (£) *Total priority debts - monthly payment (£) Support needs and ethnicity Are you happy for us to update your records with the details you provide? Yes No Please select your ethnicity - Select -White: BritishWhite: IrishWhite: Gypsy/Irish travellerWhite: Other Mixed/Mixed British: White & AsianMixed/Mixed British: White & Black CaribbeanMixed/Mixed British: White & Black AfricanAsian/Asian British: ChineseAsian/Asian British: IndianAsian/Asian British: PakistaniAsian/Asian British: BangladeshiAsian/Asian British: OtherBlack/Black British: CaribbeanBlack/Black British: AfricanBlack/Black British: OtherOther Ethnic Group: ArabOther Ethnic Group: OtherPrefer not to say Support Need information helps us adapt the services we provide, so you as our customers can access them in a safe, fair and equitable way. The list below shows a range of tasks that some customers may find more challenging due to a long-term disability or health condition (including mental health). Please tick all that apply (if you have no support needs or prefer not to say please tick the relevant box Hearing or listening Holding or grasping Learning or understanding Moving around Reading Remembering Respiratory or breathing difficulties Seeing Speaking and talking Thinking or feeling clearly Writing No support needs Prefer not to say Submit Leave this field blank