Council Tax Financial Questionnaire

Are you completing this form for yourself?(Required)

Yes

No, I am making the referral on behalf of someone

What is your relationship to the person being referred?(Required)

Carer

Family/friend

Redbridge Council staff

Other ...

if other, please specify(Required)

Title(Required)

Please selectMrMrsMissMsMxOther

if other, please specify(Required)

First name(Required)

Last name(Required)

Other names

Contact telephone number(Required)

Alternative contact number

Email

Declaration

Declaration(Required)

I declare that I have read each question to the claimant and recorded the answers given by them. As far as I know, they are true and complete.

Declaration(Required)

I declare that the information I have given is complete and accurate to the best of my knowledge. I understand that the Council may check the information against other data sources and that the option to pay by instalments may be withdrawn if I knowingly supply false information.