expense claim form

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					                                                                          EXPENSE CLAIM FORM


NURSE NAME                                                                                                  ADDRESS


AVA PAYROLL NO                                                              WEEK NO


DOB                                              NIN


DATE OF SHIFT                                                      JOURNEY DETAILS FOR TRAVEL BY CAR                                          MILEAGE




                                                                                                            Car travel          Total @ 40p



                                                                                                            Over 10,000 miles   Total @ 25p



                                                                                                            Bicycle travel      Total @ 20p




Mileage expense offset may be claimed at 40p per mile for the first 10,000 miles. All mileage above this may be claimed at 25p per mile.

Expenses claimed for traveling to and from the hospital must be submitted with your timesheet.

EXPENSE CLAIM FORM MUST CONTAINS DATES OF THE SHIFTS TO BE PROCESSED.

    SHIFT START DATE:                                                                     SHIFT END DATE:

Stationery (envelopes, stamps, faxes, photocopies)


Phone Top-up card or itemised phone bill


Travel to and from work with relevant receipts


Travel to induction, mandatory training or immunisation (only with relevant receipts)


Subsistence / Meals - NO RECEIPTS REQUIRED


Other, CRB, Training, Occ Health, Uniforms


Accommodation or staying with a friend (only when dates mentioned and full friends address provided)




                                                                                                                                TOTAL




                  Note - Receipts must be attached in order to process                                                          GRAND TOTAL




DECLARATION :

I declare that the above expenses were incurred wholly, necessarily, and exclusively in the execution of my duties


                                              Date:______________________
Signature:_______________________________________


EXPENSE CLAIMS MUST BE SIGNED IN ORDER TO BE PROCESSED AND POSTED TO:
GREAT WEST HOUSE (GW1), BRENTFORD, LONDON TW8 9DF
PLEASE NOTE THAT FAX COPIES WILL NOT BE PROCESSED.

				
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