Name: Ms Jacky Sullivan

D.O.B.: 25 Jan 1959

Application: ✓Single Joint
Partner (if applicable):
Partner D.O.B. (if applicable):
Address: ALFRED ROAD OVERSLEY HOUSE
ALFRED ROAD Case reference number: 2636294
LONDON W2 5HE Date of statement: 11 Sep 2024
Date of review (if applicable): 11 Sep 2024
Dependent children: Under 16: 0 16-18: 0 Employment: Full-time Part-time Unemployed
Other dependants: 0 ✓ Not working due to illness / disability Self-employed
Number in household: 1 Retired Carer Student Other
Number of vehicles in household: 0 Partner's employment: Full-time Part-time
Housing tenure: Unemployed Not working due to illness / disability
Owner Mortgage Tenant - private Self-employed Retired Carer Student Other
✓ Tenant - social Living with parents Other

Overview Amount (£) Notes

Total income £1,674.16
Total outgoings £1,232.00
(Savings contribution) £0.00
Total available for priority creditors £10.00
Total available for non-priority creditors £432.16

Monthly income
Earnings Amount (£) Notes
Salary or wages (take home) £0.00
Partner salary or wages (take home) £0.00
Other earnings
£0.00
(including self employment)
Total salary and wages per month £0.00

Benefits and tax credits Amount (£) Notes

Universal Credit £0.00
Jobseeker's Allowance (income based) £0.00
Income Support £790.83
Working Tax Credit £0.00
Child Tax Credit £0.00
Child Benefit £0.00
Employment and Support Allowance or
£0.00
Statutory Sick Pay
Personal independence allowance (PIP) £450.00
Carer’s Allowance £0.00
Local Housing Allowance /
£433.33
Housing Benefit
Council Tax support £0.00
Maternity allowance £0.00
Other benefits/tax credits £0.00
Total benefits and tax credits per month £1,674.16
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Monthly income (continued)
Pensions Amount (£) Notes
State pensions £0.00
Private or work pensions £0.00
Pension credit £0.00
Other pensions £0.00
Total pensions per month £0.00

Other income Amount (£) Notes

Maintenance or child support £0.00
Boarders or lodgers £0.00
Non-dependants’ contributions £0.00
Student loans and grants £0.00
Other income £0.00
Total other income per month £0.00

Monthly outgoings: Fixed Costs

Home and contents Amount (£) Notes
Rent £200.00
Ground rent & service charges
£0.00
(factor fees if you live in Scotland)
Mortgage £0.00
Mortgage endowment £0.00
Secured loans £0.00
Council tax/rates (including water charge
£10.00
if you live in Scotland and rates in NI)
Appliance & furniture rental
(including appliance and furniture HP, £100.00
conditional sale and so on)
TV licence £0.00
Other costs £200.00
Total home & contents costs per month £510.00

Utilities Amount (£) Notes

Gas £10.00
Electricity £86.67
Other expenditure £100.00
Total utilities costs per month £196.67

Water Amount (£) Notes

Water supply £43.33
Total water costs per month £43.33

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Monthly outgoings: Fixed Costs (continued)
Care and health costs Amount (£) Notes
Childcare costs £0.00
Adult-care costs £0.00
Child maintenance or child support £0.00
Prescriptions and medicines £0.00
Dentistry and opticians £0.00
Other costs £0.00
Total care and health costs per month £0.00

Transport and travel Amount (£) Notes

Public transport
£0.00
(e.g. work, school, shopping)
Vehicle finance £0.00
Car insurance £0.00
Road tax £0.00
MOT and ongoing maintenance £0.00
Breakdown cover £0.00
Fuel, parking and toll road charges £0.00
Other costs (including taxis) £0.00
Total transport
£0.00
and travel costs per month

School costs Amount (£) Notes

School uniform £0.00
After-school clubs and school trips £0.00
Other costs (e.g school fees) £0.00
Total school costs per month £0.00

Pensions and insurances Amount (£) Notes

Pension contribution £0.00
Life insurance £0.00
Mortgage payment protection insurance £0.00
Buildings and contents insurance £0.00
Health insurance
£0.00
(medical or accident or dental)
Other £0.00
Total pensions
£0.00
and insurances costs per month

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Monthly outgoings: Fixed Costs (continued)
Professional costs Amount (£) Notes
Professional courses £0.00
Union fees £0.00
Other £0.00
Total professional costs per month £0.00

Other essential costs Amount (£) Notes

£0.00
£0.00
£0.00
Total other essential costs per month £0.00

Monthly outgoings: Flexible Costs

Communications and leisure Amount (£) Notes
Home phone £0.00
Internet and broadband £76.00
Subscriptions £0.00
Mobile phone £49.00
Hobbies, leisure or sport (e.g. socialising,
eating out, outings, clubs £0.00
leisure courses)
Activities £0.00
Newspapers, magazines,
£0.00
stationery and postage
Other costs (e.g Gifts, pocket money) £100.00
Total communications and leisure
£225.00
costs per month

Food and housekeeping Amount (£) Notes

Groceries (e.g. food, pet food,
£150.00
non-alcoholic drinks, cleaning)
School meals and meals at work £0.00
Laundry and dry cleaning £0.00
Vet bills & pet insurance £0.00
House repairs and maintenance £0.00
Other costs £25.00
Total food and
£175.00
housekeeping costs per month

Personal costs Amount (£) Notes

Clothing and footwear £35.00
Hairdressing £17.00
Toiletries £0.00
Other costs £30.00
Total personal costs per month £82.00

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 Total Monthly Outgoings: (fixed and flexible)
Amount (£)
Total costs per month £1,232.00

Savings
Amount (£)
£0.00

Debts
Priority Debts
Creditor Owed (£) Offer
Service charge/ Ground rent £0.00 £10.00

Total priority debts £0.00

Non-Priority Debts
Creditor Owed (£) Offer
jd williams £200.00 £0.00

Total non-priority debts £200.00

Token payments £0.00

This financial statement is an accurate record of the information provided.

Signed: Date:

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