Download the repayment proposal form (164KB

Proposal Payment Plan
If you are unable to pay the full amount of the housing benefit overpayment as
shown on the notice but wish to propose a payment plan to clear the amount owed
please complete the following form.
*This is a mandatory field. Full Name
*This is a mandatory field. Your Full Address
*This is a mandatory field. Postcode
Address the overpayment relates to, if different to above
Daytime Phone Number
Mobile Number
Email Address
*This is a mandatory field. Housing Benefit Claim Number (begins with 1)
*This is a mandatory field. Invoice Number (begins with 5)
*This is a mandatory field. Employers Name (if not working please enter 'not
working')
*This is a mandatory field. Your Job Title (if not working please enter N/A)
*This is a mandatory field. Full Address of Workplace (if not working please enter
N/A)
*This is a mandatory field. Payroll Reference Number (if not working please enter
N/A)
*This is a mandatory field. Expected Net Earnings (after deductions/take home pay)
please state whether weekly or monthly: £ (if not working please enter N/A)
*This is a mandatory field. Which benefits do you receive?
Income Support
Job Seekers Allowance
ESA
Incapacity Benefit
DLA
Child Benefit
Tax Credits
Other
None
Do you receive a pension?
Yes
No
*This is a mandatory field. I wish to propose a payment plan of £ (please state
amount)
*This is a mandatory field. I wish to commence payment on (please state date)
*This is a mandatory field. Please choose a frequency for your payment
Weekly
Fortnightly
Monthly
Do you want to make payments by using the Paypoint reference on your demand
letter at PayPoint outlets, ?
Yes
No
Do you want to make payments by Direct Debit
Yes - Please complete direct debit details below
Payment Date for Direct Debit
1st
6th
10th
15th
21st
28th
Bank Account no.
Bank Sort Code.
Name on Bank Account.
The council will notify you in due course if your offer to clear the overpayment is
acceptable, please note that we may not accept your offer of payment if it will take
too long to clear the amount owed. Please use box below if you would like us to
consider anything else.
.