Confidential Income Statement

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.

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:

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:

1. 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.
2. 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:

1. 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.
2. 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.

‣ 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.

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

3b. Income from Other Sources

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:

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

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.