Tell us if you're struggling to pay

Name *

First name

Last name
Address*
Date of birth
Phone*
Email*
Do you have a partner?*
Partner's name

First name

Last name
What are you struggling to pay? *
Council Tax (reference starts with a 4)Council Tax Internal Enforcement (reference starts with a 3)Housing RentsBusiness RatesHousing Benefit overpayment
Council Tax account number (if selected)
Council Tax Internal Enforcement account number (if selected)
Housing Rents Reference (if selected)
Business Rates account number (if selected)
Housing Benefit overpayment reference (if selected)

Income
Please specify a weekly amount
Wages/Earnings
Pension
Tell us if you receive one of the following
If you receive one of the benefits listed above, please tell us the amount you receive
Universal Credit
Tax credits
Child benefit
Maintenance
Other (please specify)
If we have obtained a liability order against you for unpaid Council Tax, please tell us more about your income:
Name of your employer
Address of your employer
Pay number (or National Insurance Number if you do not know this)
Net Pay and how often you are paid (e.g. weekly, monthly)
National Insurance Number if you are claiming benefits
Partner details
If you have a partner, do they have any income? e.g. wages, pension, benefits etc.*

Income of Partner
Please specify a weekly amount
Wages/Earnings
Pension
Tell us if you receive one of the following
Universal Credit
Tax credits
Child benefit
Maintenance
Other (please specify)
If we have obtained a liability order against you for unpaid Council Tax, please tell us more about your income:
Name of your employer
Address of your employer
Pay number (or National Insurance Number if you do not know this)
Net Pay and how often you are paid (e.g. weekly, monthly)
National Insurance Number if you are claiming benefits

Your payments
Based on your disposable income, please tell us how much and how often you will make a payment:
How much you will pay*
How often you will make a payment*
What date will you pay this on*
Do you wish to pay via Direct Debit?*

Declaration
I certify that to the best of my knowledge and belief the information I have given is correct. You will review my offer of payment and will contact me directly using the information provided on this form to discuss this, if required. You will use the information that I have provided and share it with other Council departments including, but not limited to, Council Tax, Business Rates, Housing Rents, Income Group and Assessments. If you have obtained a liability order against me for unpaid Council Tax, you may contact my employer, where appropriate, to use this information in relation to an Attachment of Earnings. If you have obtained a liability order against me for unpaid Council Tax, you may contact the Department of Work and Pensions (DWP) to verify the information I have provided to you in relation to my benefits where appropriate, to use this information in relation to a deduction from my benefits.
I agree

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