DIRECT PAYMENT (DP) FINANCIAL MONITORING FORM
Please return your completed form and documents by:
You must also provide copies of your bank statements for the
monitoring period and copies of your payroll summaries or
payslips issued and all receipts for any other expenditure
incurred
Please Complete Pages 3, 4, 5 and 6
Please return the form and photocopied documents to:
Adults and Older People Services
Financial Assessment Team
2nd Floor Wellington Street
Woolwich SE18 6HQ
IF YOU WOULD LIKE TO RECEIVE THIS FORM ELECTRONICALLY, PLEASE
SEND AN EMAIL REQUEST TO: Directpayments@greenwich.gov.uk
IF YOU NEED SUPPORT/ASSISTANCE TO COMPLETE THE FORM PLEASE CALL
0208 921 2741
The following organisations can assist people to complete forms. To
find out how, you contact them on the numbers below
Organisation
Client Groups Supported
Greenwich Mencap
Greenwich MIND
Age Concern
Advocacy For Older People
Greenwich Carers Centre
Learning Disabilities
Mental Health
Older People
Older People
Carers
Advocacy in Greenwich
Greenwich Association of Disabled
People (GAD)
Learning Disabilities
Physical Disabilities and Sensory
Impairments
Contact
Numbers
0208 305 2245
0208 853 2395
0208 269 0298
0208 269 0298
0208 301 8675
0208 301 8679
0208 293 3720
0208 305 2221
1
This Page will be completed by the Council.
Name of DP Recipient:
Date of Birth:
(To be completed by the Access to Resources – Finance Bureau)
Date Monitoring Form Sent Out:
Please tick one of the following:
Sent by post:
Sent electronically by email:
(To be completed by the Access to Resources – Finance Bureau)
Period of Financial Monitoring: From:
to:
(The ‘from’ date should be the last date of financial monitoring to be completed by the Access to Resources –
Finance Bureau)
(To be completed by the Access to Resources – Finance Bureau)
Funding Stream
Weekly Amount
Yearly Amount
Direct Payment from Council (DP)
Independent Living Fund (ILF)
Total
DP Recipient Weekly Contribution Amount
£
2
This Page to be completed by the DP Recipient
Do you have a separate DP Bank Account: Yes/No delete as appropriate
Do you receive ILF: Yes/No delete as appropriate
Do use the same account for your DP and ILF Yes/No delete as appropriate
Do you employ staff Yes/No? Delete as appropriate
If ‘no’ you only need to complete sections A, B, D, F and G
Do you use agency staff Yes/No delete as appropriate
How many employees have you employed during this monitoring period?
How many Agency Employees have you used during this monitoring period?
If you employ staff please provide details of your Public Liability and Employer
Liability Insurance
Name of Insurer: ____________________________________
Date Policy Expires: ______/________/___________
Policy Number: ______________________________
Level of Cover: Basic Cover/Full Cover delete as appropriate
Are you registered with HMRC Yes/No?
Do you use self employed staff Yes/No?
If yes, have you established that they are registered with HMRC Yes/No? Delete as
appropriate
If you do not receive ILF put ‘0’ in the ‘amount (£) column’ on the next page. If
you do not employ staff or use agency also put ‘0’
3
Section A – MONEY CURRENTLY IN YOUR ACCOUNT
1. How much money is currently in your account £
Date:
Section B – INCOME
Payment received from the Independent Living Fund (ILF) for this £
monitoring period
Direct payments paid into your account during this monitoring £
period
2. TOTAL
£
Section C – STAFF AND AGENCY EXPENDITURE
Net wages paid to Personal Assistant/Workers during this monitoring
Period i.e. wages paid excluding Tax and National Insurance (NI)
Gross Payments made to agencies i.e. the full cost paid to agencies
during this monitoring period
Payments made to Inland Revenue (Tax and NI)
during this monitoring period
3. TOTAL
£
£
£
£
Section D – ANY OTHER COSTS/EXPENDITURE
(Please state below and enclose copies of receipts with returned completed form)
If there is not enough space, please use an extra sheet to detail this information
State any other costs incurred during this monitoring period
Amount
£
£
£
£
£
£
£
£
4. TOTAL
£
Section E – TOTAL EXPENDITURE FOR MONITORING PERIOD
5. TOTAL EXPENDITURE: Add 3 plus 4 £
SECTION F – BALANCE LEFT IN DIRECT PAYMENT BANK ACCOUNT
£
Balance left in the direct payment account at
the end of this monitoring period: 1 plus 2 less 5
4
Section G - Reserve/Surplus - If you receive ILF you can accumulate a four week
reserve of your weekly ILF amount and 8 weeks reserve of your weekly DP amount. If
you do not receive ILF you can accumulate 8 weeks reserve of your weekly DP amount.
Please state amount of reserve/surplus
£
Tick
If you are able,
please state the
approximate
amount
If you are accumulating a surplus to cover a specific
purpose please tell us what this is below:
National Insurance (NI) and Tax
£
Emergency Cover
£
Training
£
Equipment
£
Respite Break/Holiday
£
Other:
(please state)
Other:
(please state)
Other:
(please state)
Other:
(please state)
£
£
£
£
£
TOTAL
Do you wish to refund any money to the Council? Yes/No delete as appropriate
If yes, what amount?
£
Have you enclosed a cheque for this amount Yes/No? Delete as appropriate
Please make cheque payable to “Greenwich Council”. If you wish to do a bank transfer
contact us on 0208 921 2304 and we will give you the details.
5
I confirm that the information that I have provided on the Financial
Monitoring Form is a true and accurate reflection of my spending for this
monitoring period.
Name of DP Recipient:
Signature:
Name of DP Recipient Representative completing the form:
Relationship to DP Recipient:
Date form completed:
6