[[[["field7","contains","Ja"]],[["show_fields","field15,field11,field10,field9,field8"],["show_fields","field81"],["show_fields","field558,field561"]],"and"],[[["field53","contains","Ja"]],[["show_fields","field58"]],"and"],[[["field58","contains","1"]],[["show_fields","field61,field60,field59,field57,field56,field55"]],"and"],[[["field58","contains","2"]],[["show_fields","field67,field65,field64,field61,field59,field57,field568,field569"]],"and"],[[["field58","contains","3"]],[["show_fields","field73,field71,field70,field67,field65,field64,field61,field59,field57,field568,field569,field570"]],"and"],[[["field58","contains","4"]],[["show_fields","field79,field76,field77,field73,field71,field70,field67,field65,field64,field61,field59,field57,field568,field569,field570,field571"]],"and"],[[["field80","contains","Werk"]],[["show_fields","field90,field112,field248"]],"and"],[[["field80","contains","Uitkering"]],[["show_fields","field110,field117,field547"]],"and"],[[["field80","contains","Pensioen"]],[["show_fields","field110,field551"]],"and"],[[["field551","contains","WAO"]],[["show_fields","field552"]],"and"],[[["field551","contains","Aanvullend pensioen"]],[["show_fields","field553"]],"and"],[[["field80","contains","Kinderalimentatie"]],[["show_fields","field110,field114"]],"and"],[[["field80","contains","Partneralimentatie"]],[["show_fields","field110,field115"]],"and"],[[["field80","contains","Kinderopvangtoeslag"]],[["show_fields","field110,field328"]],"and"],[[["field80","contains","Huurtoeslag"]],[["show_fields","field110,field329"]],"and"],[[["field80","contains","Zorgtoeslag"]],[["show_fields","field110,field330"]],"and"],[[["field80","contains","Voorlopige teruggave Belastingdienst"]],[["show_fields","field110,field331"]],"and"],[[["field80","contains","Kostgeld"]],[["show_fields","field333,field110"]],"and"],[[["field80","contains","Studiefinanciering"]],[["show_fields","field332,field110"]],"and"],[[["field80","contains","Anders"]],[["show_fields","field110,field107,field123"]],"and"],[[["field81","contains","Werk"]],[["show_fields","field99,field249,field118"]],"and"],[[["field81","contains","Uitkering"]],[["show_fields","field548,field119"]],"and"],[[["field81","contains","Pensioen"]],[["show_fields","field549"]],"and"],[[["field549","contains","WAO"]],[["show_fields","field327"]],"and"],[[["field549","contains","Aanvullend pensioen"]],[["show_fields","field554"]],"and"],[[["field90","contains","Tijdelijk"]],[["show_fields","field92"]],"and"],[[["field99","contains","Tijdelijk"]],[["show_fields","field100"]],"and"],[[["field81","contains","Kinderalimentatie"]],[["show_fields","field121"]],"and"],[[["field81","contains","Partneralimentatie"]],[["show_fields","field122"]],"and"],[[["field81","contains","Kinderopvangtoeslag"]],[["show_fields","field334"]],"and"],[[["field81","contains","Huurtoeslag"]],[["show_fields","field335"]],"and"],[[["field81","contains","Zorgtoeslag"]],[["show_fields","field339"]],"and"],[[["field81","contains","Voorlopige teruggave Belastingdienst"]],[["show_fields","field336"]],"and"],[[["field81","contains","Kostgeld"]],[["show_fields","field337"]],"and"],[[["field81","contains","Studiefinanciering"]],[["show_fields","field338"]],"and"],[[["field81","contains","Anders"]],[["show_fields","field108,field124"]],"and"],[[["field342","contains","Auto"]],[["show_fields","field196,field194"]],"and"],[[["field342","contains","Ander vaar- en\/of voertuig"]],[["show_fields","field321,field557"]],"and"],[[["field342","contains","Aandelen \/ effecten"]],[["show_fields","field201,field195"]],"and"],[[["field342","contains","Levensverzekering en\/of koopsompolis"]],[["show_fields","field267,field341"]],"and"],[[["field342","contains","Ander vermogen en\/of bezittingen"]],[["show_fields","field340,field268"]],"and"],[[["field253","contains","Koopwoning"]],[["show_fields","field185,field186,field255,field256,field257,field258,field259,field188,field320,field254"]],"and"],[[["field320","contains","Ja"]],[["show_fields","field266"]],"and"],[[["field233","contains","Ja"]],[["show_fields","field234,field237"]],"and"],[[["field234","contains","Ja"]],[["show_fields","field235,field236"]],"and"],[[["field235","contains","Nee"]],[["show_fields","field240"]],"and"],[[["field237","contains","Ja"]],[["show_fields","field238,field239"]],"and"],[[["field238","contains","Nee"]],[["show_fields","field241"]],"and"],[[["field223","contains","Ja"]],[["show_fields","field224,field225,field229"]],"and"],[[["field43","contains","Gehuwd"],["field43","contains","Geregistreerd partnerschap"]],[["show_fields","field594"]],"or"],[[["field584","contains","Ja"]],[["show_fields","field590,field586,field589,field588,field587,field585,field583"]],"and"],[[["field594","contains","2017 of eerder"]],[["show_fields","field44"]],"and"]]
1 Step 1

  • Ieder traject is uniek. Om een goede inschatting te maken of wij u van dienst kunnen zijn, hebben wij vooraf enkele gegevens van u nodig.
  • Gegevens van eventuele partner zijn ten allen tijde noodzakelijk i.v.m. de invloed op het Vrij Te Laten Bedrag.
  • Door het invullen van het aanmeldformulier gaat u akkoord met de verwerking van uw gegevens door Van Dijk Sociaal.

1 Persoonsgegevens
Gegevens aanvrager
Heeft u een partner?
Gegevens partner
Adresgegevens aanvrager
2 Aanvullende persoonsgegevens
Kinderen
Heeft u thuiswonende kinderen?

1e Kind

2e Kind

3e Kind

4e Kind

Zijn er nog andere inwoners op uw adres ingeschreven?
3 Inkomen
Bron van inkomsten(meerdere opties mogelijk)
Dienstverband
Soort pensioen
Bron van inkomsten partner(meerdere opties mogelijk)
Dienstverband
Soort pensioen
4 Vermogen / Bezittingen
Selecteer vermogen / bezittingen(meerdere opties mogelijk)
5 Woonsituatie
Is er een overwaarde?
6 Zorgverzekering
Heeft u een zorgverzekering?
Bent u aangemeld bij het CAK wegens belastingsachterstand?
Heeft uw partner een zorgverzekering?
Is uw partner aangemeld bij het CAK wegens belastingsachterstand?
7 Over uw situatie
Is ontruiming van uw woning aangezegd?
Is afsluiting van energie of water aangezegd?
Bij welke bank(en) bankiert u?
8 Schulden
Is er eerder sprake geweest van enige vorm van schuldhulpverlening?
MSNP
Geslaagd traject?
WSNP
Geslaagd traject?
Heeft u of uw eventuele partner schulden bij het CJIB?
Heeft u of uw eventuele partner een fraudeschuld?
9 Overig
Is er momenteel een achterstand in de betaling van de huur/hypotheek, zorgverzekering of energiekosten?
Bent u momenteel in staat om zelf uw inkomsten en uitgaven volledig en correct te beheren?
Ben u momenteel in staat om in een later stadium alle noodzakelijke gegevens die benodigd zijn volledig en correct aan te leveren? (Dit betreft o.a. een volledig ingevuld intakeformulier en een flink aantal kopieën van bewijsstukken)
10 Uw gegevens, indien u dit formulier namens iemand anders invult
Vult u dit formulier voor iemand anders in?
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