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CICS Account and case numbers: 55508596 01623514

Please write in black ink.

Details of income from 26DEC06

Are you working? Yes No
£
If Yes, how much are you paid each week?

Is your partner working? Yes No
If Yes, how much is your partner paid? £

How many hours do you work?

You

Your partner
You must enclose payslips. We may contact your employer if your
payslips do not provide enough information.
Please write your employer’s name and address:

Did / do you or your partner receive any Yes No
other income or benefits, such as state
retirement pension, tax credits or incapacity
benefit?
If Yes, please list them below and provide proof

£

£

£

X:\CICDWP dot

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