HB11b - Housing Benefit and Council Tax Support Self Employed Earnings Information

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1 Benefit Service PO Box 2, Forde House Newton Abbot, TQ12 4YR Phone: Fax: HB11b - Housing Benefit and Council Tax Support Self Employed Earnings Information Section 1 - About the person who is self employed Full Name: Benefit Reference Number Address and Post Code: National Insurance Number Section 2 - About your Business Name, address and post code of business Business Telephone Number: Type of Business: Start and end dates of your financial year Start: End: Average number of hours worked per week Is your business a partnership? (if so provide your partnership agreement) Yes No hrs If Yes, what percentage of the total profit or loss is yours? % Is your partner or civil partner a partner in the business? Yes No If Yes, what percentage of the profit or loss is theirs? % Is your partner or civil partner on the payroll of the business? Yes No If Yes, what is his/her earnings? Are there other people on the payroll of the business? Yes No 1

2 Do you use part of your own home for business purposes? Yes No If Yes, give details Are you registered with HM Revenue and Customs as self employed? Yes No Section 3 - Accounts Do you have any prepared accounts (audited or otherwise) for your last financial year? If Yes, return a copy with this form If No, please give the reason why and the date you expect to have them Yes No If you do not have any prepared accounts for your last financial year, or if you have not been trading for a full year, please complete section 4 of this form. If you have prepared accounts for the last financial year go to section 5 Section 4 - Income and Expenditure State the exact date covered. This should be your last full financial year or if you have not been trading for a year it should be from the date your business started to the current date From: To: Income Payments received for services and goods supplied Rent from (sub) letting of business premises Interest on monies held in bank accounts etc Tips and gratuities VAT collected ( if VAT registered trader) VAT refunded New Deal payments Total of other business related income separate sheet - please specify details on Less - Cost of Sales (purchases made for re-sale) Less - VAT paid out Gross Income 2

3 Expenditure You must only put down amounts that relate solely to the business Please note - Not all expenditure accepted by the Inland Revenue is acceptable for the assessment of Housing Benefit & Council Tax Support On Business premises: Rent - Water Charges - Rates - Insurance Premiums - Total Any portion of the home used solely for business purposes i.e. an annexe or room. State what you consider to be the cost and percentage used. % Heating and Lighting Mortgage and Loan interest connected to the business Telephone, fax etc Capital repayments on any loan used to repair an existing asset but only to the extent that the loan exceeds any sum paid or due to be paid under an insurance policy for that repair Capital repayments on any loan used to replace an item of equipment or machinery which has worn out in the course of business or has become outdated Interest payable under a credit sale, a consumer credit agreement or a hire purchase agreement (but not the capital elements of such payments) Sum spent on the repair of an existing business asset but only to the extent that the cost of the repair exceeds any sum paid or due to be paid under an insurance policy for that repair Hire, rental or lease costs (but not any capital or purchase elements) Advertising Printing and Stationery Postage Sundries / miscellaneous items Clothing supplied i.e. uniform Cleaning of business premises Sub Total 3

4 Transport Costs - use of car, local transport etc for business purposes Do not include home to work costs unless you work from home Road Tax - Petrol Costs - Insurance - Servicing / Repairs - Deduct personal usage before stating amounts Who owns the vehicle Name: What percentage is for personal use Have you excluded amounts for personal use from the above figures? Other Expenses Total Yes No % Drawings Wages paid to partner or civil partner Employees wages Employer s NI contributions and employer s contributions to a pension scheme which is approved by the Inland Revenue and the Occupational Pensions Board in respect of any employee Legal fees and or accountancy charges connected to the business Any other expenses not specified Gross Expenditure You may be required to provide proof of any expense items listed. The Council will contact you if necessary. Section 5 Is it reasonable to assume that the trading figures for the next twelve months will be similar to those given or the accounts enclosed? Yes No If No, please explain the likely differences: 4

5 Section 6 - Other Outgoings National Insurance Do you hold an exemption certificate? Yes No If No, state how much you pay and please provide evidence of your National Insurance Contributions every: Personal Pension Contributions State how much you pay. Provide proof of the scheme to which you belong and what you pay. every: Section 7 - Declaration Please read this declaration carefully before you sign and date it. I understand the following: If I give information that is incorrect or incomplete, you may take action against me. You will use the information I have provided to process my claim for Housing Benefit and / or Council Tax Support. You may check some of the information with other sources within the Council, Rent Offices and other Councils. You may use any information I have provided in connection with this and any other claim for Social Security benefits that I have or may make. You may give some Information to other government organisations, if the law allows this. I understand that any information I provide may be data matched with other government departments and organisations including credit reference agencies. I authorise the council to make any necessary enquiries to check the information in this form. I am aware that I must let the council s benefit office know about any changes in my circumstances which might affect my claim. I declare that the information I have given on this form is correct and complete. Signature of person claiming Housing Benefit and / or Council Tax Support Signature Date Contact Number HB11b V5 12 Feb 13 5