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Partial Fee Waiver form
Partial Fee Wavier application
Step
1
of
9
11%
Criteria
(Required)
Have had a recent change in circumstances
Expressing concern regarding finances and/or payment
Low income/joint income (less then 35K household)
Single parent household earning less than 35K
Other
Other – Please specify
(Required)
I understand this form needs to be returned a minimum of 2 months before my assessment date
(Required)
Unless agreed otherwise with the family service team
Yes
I understand that incomplete information may result in a delay processing my application
(Required)
Yes
I agree and understand I have read the following information
(Required)
A minimum of two months of bank statements will be provided from each parent/carer within the house hold, these statements show all income and outgoing transactions stated on the form. Multiple bank accounts may be submitted.
Yes
Parent/Carer
(Required)
First
Last
Child/young person
(Required)
First
Last
Assessment information
(Required)
Assessment booked
Assessment not booked
Assessment date
(Required)
MM slash DD slash YYYY
Monthly income into household
Household
(Required)
Single household
Joint household
Employment status
(Required)
Full-time Employment
Part-time Employment
Self-employed
Unemployed
Total Monthly wage/income
(Required)
Second parent/carer – Employment status
(Required)
Full-time Employment
Part-time Employment
Self-employed
Unemployed
Total Monthly wage/income
(Required)
Do you receive Benefits? (including child benefit)
(Required)
Yes
No
Monthly Amount
(Required)
Do you currently receive a pension payment?
(Required)
Yes
No
Monthly Amount
(Required)
Do you have any investments/ISAs or savings?
(Required)
Savings
Investments
ISA
Other – please specify below
None of the above
Saving amount
Investment amount
ISA amount
Other amount
Please specify what in box including about
Monthly outgoings
Do you have a mortgage or pay rent?
(Required)
Mortgage
Rent
Other
Rent monthly amount
(Required)
Mortgage monthly amount
(Required)
Other monthly amount
(Required)
Please specify in box including monthly amount
House Insurance (Building and/or contents)
Water
Monthly amount
Gas and Electricity
(Required)
Combined
Seprate
Other – Oil
Gas and Electricity
Monthly amount
Gas
Monthly amount
Electricity
Monthly amount
Oil
Monthly amount
Council tax
Monthly amount
TV Licence
Monthly amount
Internet
Monthly amount
Landline
Monthly amount
Mobile Phone
Monthly amount – If more than one please specify
Do you have any existing debts
(Required)
This includes things such as loans, credit cards/store cards, finance and arrears.
Yes
No
Loans
Monthly amount
Credit Card/store card
Monthly amount
Finance
Monthly amount – Please specify what, include items such as car, clothing, electrical and furniture.
Arrears
Monthly amount – For example Rent, Council tax, Water Utilities
Do you have any vehicles in the household
(Required)
Yes
No
Number of vehicles in household
(Required)
Paid for by parent/carer
One
Two
More than two
Vehicle one insurance
Monthly amount
Vehicle two insurance
Monthly amount
Other vehicles insurance
Monthly amount
Vehicle one – tax
Monthly amount
Vehicle two – tax
Monthly amount
Other vehicles – tax
Monthly amount
Vehicle one
Monthly amount
Vehicle two
Monthly amount
Other vehicles
Monthly amount
Car Maintenance
Monthly amount
Additional travel costs
Bus, train, parking, taxi
Supermarket shop
Approximate monthly food shop cost
Do you have any childcare costs?
Yes
No
Monthly amount
Monthly subscriptions
Please select all that apply
Netflix
Apple TV
Sky
Now TV
Amazon Prime
Spotify
Audible
Magazine Subscriptions
Disney Plus
Other
Netflix
Monthly amount
Apple TV
Monthly amount
Sky
Monthly amount
Now TV
Monthly amount
Amazon Prime
Monthly amount
Spotify
Monthly amount
Audible
Monthly amount
Magazine Subscriptions
Monthly amount
Disney Plus
Monthly amount
Other
Please Specify
Additional outgoings
With the following if you have more then one plan, combine the totals. For example two life insurance plans, combine the cost of both for an overall total.
Life Insurance
Monthly amount
Health cover
Monthly amount
Dental Plan
Monthly amount
Pet insurance
Monthly amount
Pet cost
Monthly amount
Prescriptions
Monthly amount
General
Please specify – Monthly amount
Clothes
Monthly amount
I confirm that the information given in this form is true, complete and correct
(Required)
Yes
No
File
(Required)
Drop files here or
Select files
Max. file size: 8 MB.
Name
This field is for validation purposes and should be left unchanged.
