**Please complete in block letters by 649v7x0E


									Appendix A – NHS Wirral Travel & Subsistence Claim Form V2.0 April 2010
                      **Please complete in block letters. Your claim will be returned if all relevant details are not fully completed**
Travel & Subsistence Claim for the Month of:             20    Full Name:

Payroll No:         Department No: 660 z                 Home Address:

Base:                                                    Department:

Job Title:                                               Band:

Email Address:                                           Line Manager’s Email Address:
                         ** Please complete this section if you require reimbursement for course or conference expenses only**
                                  Note - * indicates that a receipt must be attached before reimbursement can be made
   Date of     Course/Conference       Full details of           Mileage                    R = Rail      T = Taxi     Accomm      Course fee     Subsistence – Times spent on
   Journey     Attended                journey                   (No of miles)              B = Bus       TL =         -odation        *          Official Business
                                                                                            P = Parking   Tunnel           *
                                                                 Official   PTR     Pass    £.P           Type         £ .p        £. p           From         To       £. p

I Declare That:
(a)     The Travelling Expenses Allowances claimed are in accordance with the terms and conditions of service determined from time to time and have not been claimed from any
other authority; where day Subsistence Allowances are claimed, I spent more on meals than if I had been at my permanent base, and where an allowance for more than 8 hours is
claimed, I necessarily incurred expenditure on an additional meal.
(b)     The Claim for mileage allowance is in respect of a          CC car         Make:                     Model:                     Reg:
(c)     Is this the first time you are making a claim for this vehicle? Yes      No
(d)     To the best of my knowledge and belief my car was roadworthy throughout this period covered by the claim and I hold a valid UK Driving Licence.
(e)     I declare this is a true and accurate record of the mileage I have undertaken in relation to my duties.
(f)     My Insurance Company is unchanged/has changed to

Signature:                                                                   Print Name:                                                  Date:

                                                               Lease Car Users – Please Complete Mileage
   Start Mileage:                                             Finish Mileage:                                             Vehicle Registration:

Authorisation: I certify to the best of my knowledge and belief, the Claimant was engaged on the duty stated on the dates shown above. I further declare that I have checked the
following documents within the past 12 months to ensure the driver is legally entitled to use their vehicle on NHS business: Driving Licence:     MOT Certificate:

Signature:                                                                  Print Name:                                                   Date:

   Claim From           Claim To               No. of Days        General Mileage           General Expenses         Course Expenses              Date of Payment
Appendix A – NHS Wirral Travel & Subsistence Claim Form V2.0 April 2010
                                                                                  CAR MILEAGE – No. of Miles               Other Travel          Subsistence
  Date of           Purpose                 Full details of journey        Off    PTR      Home     On Call    Pass    R=Rail T=Taxi      Time spent on    Amount
  Journey                                      (Block Letters)            Miles   Miles   to Duty    Miles     Miles   B=Bus P=Parking      business
                                                                                                                       £     .p    Type   From       To        £   .p

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