Fuel Card Opt Out Form
w Please complete this form to opt out of the company car fuel card.
w The form should be emailed to PBS Fuelcard and PBS Carexpenses or faxed to Payroll and Benefits Services on
w Please note that that you need to allow at least 1 week processing time.
w Receipt of the form in Cardiff will be acknowledged. If you do not receive acknowledgement within 1 week, please
contact the Payroll and Benefits Services Call Centre on 52994 or email PBS CC.
w Your fuel card will be cancelled on the date notified by Payroll and Benefits Services and must not be used after
this date. You must return the card, within 1 week of this date to Payroll and Benefits Services, Finance Service
Employee number (shown on your payslip):
NI number (shown on your payslip):
Work Level/Store Category:
Department / Job Title:
Line Manager name:
Company car make and model:
Company car registration:
Fuel Card Number:
I confirm that I would like to opt out of the company fuel card:
Employee Signature: Date:
Personnel Managers Signature: Date:
(Please sign if you are sending the form via fax or send the form from your own email account)
We will inform the Inland Revenue if you make a change to your fuel card option so that they can adjust your tax
You may wish to contact the Inland Revenue yourself to ensure prompt adjustment of your tax code. They can be
contacted at the following address:
HM Inspector of Taxes
LP Lothians District
5 Bankhead Avenue
or you can telephone them on 08453 021409. NB You will need to quote your National Insurance number (found on
your payslip) and the Tesco tax reference which is 846 / T1.