Confidential Income Statement

"*" indicates required fields

Please provide full details of your household income by completing all sections of the following form.

Alternatively you can download, print and complete a PDF version of this form and post it back into us. Download Form.

Your name:*

First Name Surname

Nomination Scheme Name or Address*

Are you:*

currently applying for housing with Circle VHA?

already a tenant with Circle VHA?

Your Occupancy ID:*

Preparation checklist

This form may require a number of documents to be uploaded depending on your individual circumstances. These documents can be either digitally photographed using a camera or camera-phone, or you can scan them in.

To find out what documents you will need to photograph/scan and upload before starting the form process, please choose from the options below:

Do you or any member of your household receive welfare payments?*

Yes

Are you or any member of your household currently employed?*

Yes

Are you or any member of your household currently self-employed?*

Yes

Are you or any member of your household currently unemployed?*

Yes

Are you or any member of your household currently part of a Community Employment (CE) programme?*

Yes

Are you or any member of your household currently receiving a pension?*

Yes

Are any members of your household (aged 18 or over) in full time education?*

Yes

Have you, or any member of your household, earned interest on savings, dividends on shares or received any other income with a value greater than €100 in the past year?*

Yes

Documents you need to prepare before starting this form:

‣ Completed Social Welfare Form or Statement

If you, or any member of your household, are in receipt of a welfare payment you must either:

Download and print out the Social Welfare Form using the button below and then have it completed and signed by The Department of Social Protection.
Or request a statement online from the Social Welfare website using the ‘Request Statement’ button below.

Once you have either your completed and signed printed PDF form from the Social Welfare Office or the statement you received in the post from your online Social Welfare website request, you can photograph either of them and upload them in section 3 of the form.

‣ Three current social welfare slips

You will also need to photograph and upload photographs of 3 current social welfare slips in section 3 of the form.

‣ Employment Documents

You will need to upload a photograph of a current P60 or 3 current pay slips for each employed person in your household.

‣ Self-Employed Documents

You will need to upload a photograph/s of a the most recent tax returns or set of accounts for each self-employed person in your household.

‣ Unemployed Documents

You will need to upload a photograph of a current P45 for each unemployed person in your household.

‣ Community Employment (CE) programme Documents

You will need to upload a photograph of a letter confirming pay and attendance at CE Scheme for each person in your household that is on a CE programme.

‣ Private Pension Documents

If you or anyone in your household is currently in receipt of a private, occupational or foreign pension, you will need to upload a photograph of an up to date statement from your pension provider to confirm the total amount received.

‣ Irish State Pension

If you, or any member of your household, are in receipt of an Irish State Pension you must either:

Download and print out the Social Welfare Form using the button below and then have it completed and signed by The Department of Social Protection.
Or request a statement online from the Social Welfare website.

‣ Documents for full time students

For each person in your household (aged over 18) and in full time education, you will need to upload a photograph of a letter from the School or College confirming their attendance.

‣ Documents for Interest on Savings or Dividends

Please upload a photograph of relevant documentation if you or a member of your household has earned interest on savings, dividends on shares or received any other income with a value greater than €100 in the past year.

Are you ready to continue?

If you have photographs or PDFs of the requested list of documents above, please click on the NEXT button below.

If you don’t have all the listed documents, you won’t be able to complete the following form. Please obtain the items in the list and come back to this form when you have everything ready.

Thank you.

Section 1 – Household Details

Your address:*

Street Address Address Line 2 City County / State / Region Eircode

Your phone number:*

Your email address:*

Members of your household:

Please list all members of the household, including all children and dependents in this section. If there have been new additions to your household, please include.

Name:	Relationship:	Date of birth:	Resident since:	PPS Number:	Current Occupation:	Actions

There are no Members.

Maximum number of members reached.

Section 2 – Emergency Contacts

Information provided on this form is strictly confidential, contact details will only be used in the event of an emergency.

Emergency Contacts:

Name	Relationship:	Address:	Contact number:	Actions

There are no Contacts.

Maximum number of contacts reached.

Section 3 – Income Details

Please provide full details of your household income by completing all sections of the following form.

Failure to provide your full household income or information requested will result in the application of penalties as per your tenancy agreement.

Failure to provide the necessary documentation to establish income levels represents a breach of tenancy agreement and could jeopardise your tenancy with Circle VHA.

3a. Income from Employment/Pension

Details of all dependents over the age of 18 years not in full time education must be included below.

Name:	Type of Employment/Pension:	Date of income change:	Weekly Income:	Actions

There are no People.

Maximum number of people reached.

3b. Income from Other Sources

(Child maintenance, jobseekers, carers allowance, disability allowance etc.)

Name:	Type of Income:	Date of income change:	Weekly Income:	Actions

There are no Sources.

Maximum number of sources reached.

3c. Interest on Savings or Dividends

If you or a member of your household has earned interest on savings, dividends on shares or received any other income with a value greater than €100 in the past year, please enter the amount below:

Amount of interest received:

You will upload documents, relevant to the above, in the next section.

Upload your documents

Based on the answers you submitted at the start of the form in the ‘Preparation Checklist’, you will need to upload the following documents:

‣ Completed Social Welfare Form or Statement for each person in your household in receipt of a welfare payment.

‣ Current P60 or 3 current pay slips for each employed person in your household.

‣ Recent tax returns or set of accounts for each self-employed person in your household.

‣ A current P45 for each unemployed person in your household.

‣ A letter confirming attendance on CE Scheme for each person in your household that is on a CE programme.

‣ An up to date statement from your pension provider and/or a completed Social Welfare Form or Statement regarding your Irish State Pension.

‣ A letter from the School or College confirming attendance.

‣ Relevant documentation showing earned interest on savings, dividends on shares or received any other income with a value greater than €100 in the past year.

Document Uploader

Use this to upload photographs, scans or pdf’s of your requested documents.

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 50 MB, Max. files: 20.

Section 4 – Declaration

Please read the statements below carefully and check the relevant check boxes.

I/We declare that the income details as provided are a full and an up to date accurate statement of my/our household income.

I/We authorise and give authorisation for Circle Voluntary Housing Association to seek and receive any information which Circle Voluntary Housing Association may require from my/our employer or The Department of Social Protection or from any source in relation to income.

I/We are aware that it is a condition of my/our tenancy agreement that the inclusion of false information or omission of any income details is a breach of my/our tenancy agreement and may jeopardise my/our tenancy with Circle Voluntary Housing Association.

Consent*

I agree to the declaration statement above.

Name*

First Middle Last

Name

First Middle Last

Date*

DD slash MM slash YYYY

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