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Income Threshold declaration

"*" indicates required fields

Step 1 of 3 – Personal Details

33%

Personal Details

Given Names*

Family Name*

Mobile Tel

Home Tel

Email

Income from Employment

Do you receive income from employment*

Yes

No

Please enter your total gross income (before tax) from employment per

Pay period*

Week

Month

Annual

Week*

(calculated annual earnings)

Month*

(calculated annual earnings)

or Year*

Evidence of Wage

You must provide evidence of your wage, this can be in the form of:

a payslip (within previous 3 months)
Universal Credit statement (within previous 3 months)
a Contract of Employment stating salary
Self-Employed Only – a Tax Return for the previous year

File Upload*

Drop files here or

Accepted file types: (jpg, jpeg, png, pdf, tiff, bmp), Max. file size: 10 MB.

Evidence provided*

please select the evidence you have provided

Payslip (within previous 3 months)

Universal Credit Statement

Contract of Employment stating salary

Self-Employed only – Tax return for previous year

Date of Evidence*

Please provide the date of your evidence, for example the date on your statement or payslip

DD slash MM slash YYYY

Declaration

Please note that these figure may be overridden if staff see different amounts of income on uploaded evidence or for joint benefit claims.

Total Annual Income

Total Annual Income

Total Annual Income

Declaration 1*

I declare that all of the information I have provided is accurate and is a true reflection of my employment status.

Declaration 2*

I understand that if I have declared false information Skills & Learning may take action against me to reclaim fees and any support costs provided.

This field is hidden when viewing the form

Signature*

Please draw your signature either with your mouse or if you have a touchscreen with your finger or stylus.

Today's Date:*

Day

Month

Year

This field is hidden when viewing the form

Staff Notes and Summary

Please provide some summary notes of your threshold assessment. Your notes may be used in future audits to provide evidence for a learners funding decision.

This field is hidden when viewing the form

Staff Signature

Please draw your signature either with your mouse or if you have a touchscreen with your finger or stylus.

I confirm that to the best of my knowledge, the information on this form is true and accurate.

This field is hidden when viewing the form

Date Signed

DD slash MM slash YYYY

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