TRAVELLING & SUBSISTENCE CLAIM by etssetcf

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TRAVELLING & SUBSISTENCE CLAIM

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									                    Completion of these boxes is mandatory                                                   TRAVEL, ASSOCIATED EXPENSES AND LEASED CAR CLAIM FORM
 Weekly / Monthly
      Paid
                      Pay
                    Division
                                Group
                                Code
                                          Pay
                                          Point
                                                               Pay Number
                                                              (8 characters)
                                                                                                                        NON MEDICAL & DENTAL STAFF ONLY

   W / M*                                                                              EMPLOYER
                           Please refer to your current payslip                     (PRIOR TO COMPLETION OF THIS FORM PLEASE REFER TO THE GUIDANCE NOTES. ALL SHADED AREAS MUST BE COMPLETED)



CLAIM FOR THE MONTH OF

EMPLOYEE DETAILS (Please use BLOCK CAPITALS)                                                                                VEHICLE / USER DETAILS                                                       EXCESS TRAVEL (See Guidance)
                                                                                                                            USER TYPE                               REG / STD / PTR / LC *
                                                                                                                                                                                                         TEMPORARY / PERMANENT * CHANGE OF BASE
NAME
(as per current payslip)                                                                                                    ENGINE SIZE (cc) OF VEHICLE USED
                                                                                                                                                                                                         EXCESS RETURN MILEAGE /
HOME ADDRESS                                                                                                                LEASED CARS ONLY                                                                                                                    (A)
                                                                                                                                                                                                         COST * FOR HOME TO BASE
                                                                                                                            CAR REGISTRATION NUMBER

                                                                                                                            ODOMETER                END OF MONTH
                                                                                                                                                                                                         NO OF DAYS / OCCASIONS
                                                                                                                            READING AT                                                                                                                          (B)
                                                                                                                                                                                                         TRAVELLED / CLAIMED
                                                                                                                                                    START OF MONTH
DESIGNATION
                                                                                                                                                    BUSINESS MILES
                                                                                                                                                                                                         TOTAL MILES / COST * CLAIMED                           (A x B)
BASE                                                                                                                                                PRIVATE MILES



CAR CHANGED SINCE LAST CLAIM? YES / NO *                                                                           IF 'YES' PLEASE ATTACH A COPY OF YOUR INSURANCE POLICY                                DATE OF CHANGE?                     /              /
                                                          DETAILS OF JOURNEY                                                       MILEAGE                                                                         EXPENSES
                    JOURNEY
                     REASON




                                                                                                  HOME TO        BASE TO
                       FOR




       DATE                                       (INCLUDING NAMES OF PASSENGERS)                                                                 PUBLIC                               TIME OF                                                     AMOUNT CLAIMED
                                                                                                 TEMPORARY     TEMPORARY           BUSINESS                     PASSENGER                                  DETAILS OF SUBSISTENCE OR OTHER
                                                                                                                                                TRANSPORT
                                                       OR DESCRIPTION OF CLAIM                   WORKPLACE     WORKPLACE           MILEAGE                       MILEAGE                                          EXPENSES CLAIMED
                                                                                                                                                 MILEAGE                       DEPARTURE        RETURN                                                  £             p
                                                                                                  MILEAGE       MILEAGE
[1]                 [2]         [3]                                                            [4]           [5]             [6]              [7]             [8]               [9]          [10]        [11]                                    [12]




   CARRIED FORWARD

   * Please delete as appropriate
                                                     DETAILS OF JOURNEY                                                               MILEAGE                                                                         EXPENSES




                     JOURNEY
                      REASON
                                                                                                  HOME TO           BASE TO




                        FOR
       DATE                                   (INCLUDING NAMES OF PASSENGERS)                                                                        PUBLIC                               TIME OF                                                   AMOUNT CLAIMED
                                                                                                 TEMPORARY        TEMPORARY           BUSINESS                      PASSENGER                                 DETAILS OF SUBSISTENCE OR OTHER
                                                                                                                                                   TRANSPORT
                                                   OR DESCRIPTION OF CLAIM                       WORKPLACE        WORKPLACE           MILEAGE                        MILEAGE                                         EXPENSES CLAIMED
                                                                                                                                                    MILEAGE                       DEPARTURE      RETURN                                                 £       p
                                                                                                  MILEAGE          MILEAGE
[1]                  [2]       [3]                                                             [4]              [5]             [6]              [7]              [8]             [9]         [10]          [11]                                [12]

     BROUGHT FORWARD




     TOTALS


     EMPLOYEE CERTIFICATION                                                                                           CERTIFYING OFFICER'S AUTHORISATION                                                           FOR EXPENSES USE ONLY:

   I HEREBY CERTIFY THAT:                                                                                             I AUTHORISE REIMBURSEMENT OF THIS CLAIM WHICH I HAVE EXAMINED. THE CLAIM APPEARS TO           NO. OF DAYS:
1)      THE ABOVE EXPENSES WERE INCURRED WHOLLY, EXCLUSIVELY AND NECESSARILY IN THE PERFORMANCE OF MY                 BE IN ORDER AND IS CONSISTENT WITH THE CLAIMANT'S DUTIES AND CONDITIONS OF SERVICE
        NHS DUTIES, AND ARE CLAIMED IN ACCORDANCE WITH MY EMPLOYERS POLICY.                                           AND EMPLOYERS POLICY.                                                                             CODE                           AMOUNT

2)         THE ABOVE EXPENSES WILL NOT BE CLAIMED FROM ANY OTHER SOURCE.                                                                                                                                                                        £
                                                                                                                      SIGNATURE
3)         WHERE I HAVE USED MY PRIVATE VEHICLE:                                                                                                                                                                                                £
      a)    MY CURRENT MOTOR INSURANCE COVERS AT LEAST THIRD PARTY RISK, INCLUDING RISK OF INJURY TO OR DEATH
            OF PASSENGERS AND DAMAGE TO PROPERTY, AS WELL AS ITS USE ON OFFICIAL NHS BUSINESS. I ACKNOWLEDGE          NAME                                                                                                                      £
            THAT MY EMPLOYER CANNOT ACCEPT RESPONSIBILITY IN RESPECT OF RISKS NOT COVERED BY MY MOTOR                 (BLOCK CAPITALS PLEASE)
            INSURANCE POLICY.                                                                                                                                                                                                                   £
            AND                                                                                                       DESIGNATION
      b)    I HAVE A CURRENT FULL DRIVING LICENCE AND A VALID MOT (WHERE APPLICABLE)                                                                                                                                                            £

                                                                                                                      DATE                                                                                                                      £
     SIGNATURE                                                         DATE

                                     TO GUARANTEE PAYMENT THIS FORM MUST BE COMPLETED CORRECTLY AND REACH THE PAY / EXPENSES DEPARTMENT BY THE 7TH OF THE MONTH

								
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