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 Taxi Ferry Underground Tram Example: 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. Example: 12-Feb-12 8.00 11.00 Brixton FLA Gross 3 14.58 43.74 Rota visit Subtotals Total Claim Rates: Bicycle 28p per mile Car/Motorcycle/Moped: 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 1101-1549cc 1550cc+ Hybrid, Dual Fuel, Electric, LPG/Gas Example: 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 Declaration Your Declaration - ALL SECTIONS MUST BE COMPLETED INCLUDING "NIL" ENTRIES 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 Certification 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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