Independent Monitoring Board - Board Members Travel and Subsitence by gp4uG1n


									                                                        Independent Board Members Travel and Subsistence Claim Form
                                                        Version Apr. 2012

                                                        If handwritten, please complete in block capitals with black or blue ink only.

Personal Details - please complete in full
Note: you must enter your name in the same form as is on your CRB check.

Title               First Name                                                     Last Name                                        Phone

IMB Member Number                                                             Name of Establishment

Are you a Dual Member?                            For chairs only - are you a chair of a contracted prison?

NOTE: The details set up against your account will be used for the payment. If you have recently had changes to your personal details-name, bank
account, address, etc - then an IMB Data Set Up And Amendment form must be completed and submitted for processing. Please allow at least 7 working
days between submission of the Data Set Up And Amendment form and submission of your next claim form.

Have you recently changed personal details?                                         If yes, when was your request submitted?

Reason for Claim - please tick one option only: a separate form must be used for each claim category.
                                                              For Liberata only:                                                            For Liberata only:
        Normal duties funded by home establishment                      -                                     Finance Loss Allowance                  -

                Ad hoc/visits to other establishments                  161                                            National Council               001

                                    Communications                     002                          National Council - Working Groups                001

                                            Diversity                  004                      National Council - Network of Speakers               001

                           Independent Interviewers                    005                                           National Training               003

                                         Conference                    018
                                                                                Receipt Based Claim Items

Claim Details                                                           Journey Details Only                                                                  Claim
    Date               Itemise claim detail     Expenditure Type           From location              To location      Method of travel     Class of ticket      Amount
 dd/mm/yy              Max 20 characters          Choose from:                                                          Choose from:         For rail and          £
                                                     Journey                                                          Air - International      air travel
                                                     Parking                                                                Air - UK             only.
                                                    Toll bridge                                                     Bus/Coach - Overseas         Enter
                                               Congestion Charge                                                      Bus/Coach - UK        Standard only.
                                              Other non-travel spend                                                          Rail
 12-Feb-12      Training                      Journey                  Thornton Heath          Victoria             Rail                    Standard                 7.50

                                                                                                                                              Total claim
                                                                                             Note, maximum rates allowed are: Day subsistence (4-8 hours)          £7.45
                                                                                                                              Day subsistence (8-12 hours)         £10.38
                                                         Financial Loss Allowance/Subsistence Form                            Day subsistence (+12 hours)          £19.6
                                                                                                                              Gross FLA                            £14.58 per hour
                                                                                                                              Net FLA                              £11.66 per hour

Claim Details                                                                                                 FLA Only                                             Claim reason
    Date        Depart     Arrive             Location                     Claim basis               Sub-         If FLA state     FLA        FLA       FLA            Nature of duty and reason for claim.
  dd/mm/yy       time     or return                                        Select from:            sistence       net or gross.   Hours       Rate      Claim
                            time                                  Daily Subsistence (4-8 hours)    amount            Select                               £
                                                                  Daily Subsistence (8-12 hours)       £              Gross
                                                                  Daily Subsistence (+12 hours)                 (Self employed)
                                                                               FLA                                   or Net
                                                                                                               (Employed) only.
  12-Feb-12        8.00       11.00 Brixton                    FLA                                            Gross                       3    14.58         43.74 Rota visit


                                                                                     Total Claim
                                                                                       Rates:          Bicycle                                             28p per mile
                                                                                                       up to 1100cc                                        35p per mile
                                                     Mileage Based Claim Items                         1101 to 1549cc                                      43p per mile
                                                                                                       over 1550cc                                         57p per mile
                                                                                                       Hybrid, Dual Fuel, Electric, LPG, Gas.              57p per mile
                                                                                                       Passengers                                          +6p per passenger per mile

                                                                          Journey Details
  Date          From location         To location     Vehicle Type       Mileage   Rate per               Claim       Number of     Passenger     Total              Reason for Journey
dd/mm/yy                                              Choose from:       claimed      mile               subtotal       pass-        supple-      claim
                                                         Bicycle                                                       engers         ment
                                                      Up to 1100cc                                                                   subtotal
                                                    Hybrid, Dual Fuel,
                                                    Electric, LPG/Gas
 12-Feb-12 Thornton Heath       Westminster         1101 to 1549cc               9.3            0.43           4.00            1           0.56       4.56 National training meeting

                                                                                                                                   Total claim
                                                                            Independent Board Members Travel and Subsistence Claim Form

I declare that,
1. I have not knowingly made any false statements in the preparation of this claim. I am aware that               5. I *do/do not hold a season ticket for the return journey between my home and my Board. (*Delete
submitting a false claim, or a duplicate claim, may lead to disciplinary action.                                  as appropriate).
2. I am aware of the requirement that claims over three months old must not be                                    6. I * have/have not been issued with an air/rail ticket centrally.
submitted without prior Secretariat agreement, as detailed in the Finance Manual.                                 7. (For motor mileage allowance claims only) I hold a valid driving licence, and my motor insurance
3. All the expenses I claim on this form have been actually and necessarily disbursed on the Public               policy covers the use of the vehicle for Public Voluntary Duties. I know and understand the insurance
Service.                                                                                                          requirements contained in the Finance Manual.
4. No other claim in respect of any of the items included in this account has been or will be made                8. (For FLA only) I know and understand the requirements contained in the Finance Manual. An
against this Department or any other Government Department.                                                       appropriate and current letter is attached/on file.

     Claimant's signature                                                                                                  Date

Checked by:
1. All local duty claims are checked, in the first instance, by the Clerk to the IMB who confirms that the claim is in accordance with the policy detailed in the Clerk's Finance Manual, and that the allowance rates are
correct. Receipts should be retained with copy forms held in the IMB office. Any receipts sent to Liberata will be destroyed.

       Name                                                     Signature                                                               Grade                           Date

1. The certifying officer is EO or above or, in the case of contracted-out prisons, the Board Chair.
2. Do not return this form to the claimant after you have completed this section.

I certify that,
1. To the best of my knowledge the journeys for which expenses and allowances are claimed were necessary, were made on official business, and were arranged so that a minimum of expense was incurred.

2. I have checked this claim in accordance with policy detailed in the IMB Clerk's Finance Manual and authorise payment. I confirm that I have seen a valid receipt where necessary. I am aware that this claim may
be subject to a post payment check, and that I may be contacted by the IMB Secretariat for an explanation should there be any discrepancies.

       Name                                                     Signature                                                               Grade                           Date

    Address                                                                                                                                                           Phone

                            On completion please send the entire form in hard copy to PO Box 697, Caerleon House, Cleppa Park, Newport NP10 8ZF.

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