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Document Sample
Claim for Reimbursement of Out of Pocket Expenses Reference
v.1.2
PAY14
Claimant Details
Title Forename Surname SAP Per No. Job Title Establishment Month of Claim Year
80
Claim Details Wage Type 3400 3410 Claim Details Wage Type 3400 3410
Amount Amount
Reason For Incurring Out of Amount Reason for Incurring Out of Amount
Date Less Date Less
Pocket Expenses of VAT Pocket Expenses of VAT
VAT VAT
2 0 2 0
2 0 2 0
2 0 2 0
2 0 2 0
2 0 2 0
2 0 2 0
2 0 2 0
2 0 2 0
* Where applicable state full value under Wage Type 3400
Additional Comments
Note 1 Completed and authorised claims should be forwarded to SERCO Payroll Services, PO Box 2681, Uckfield, East Sussex, TN22 1WT.
Note 2 The expenditure claimed for reimbursement above, must Declaration by Authorisation Officer
be supported by attached receipts. I certify that the particulars of this claim are correct and are in accordance with the County Council policy applicable to the
reimbursement of Out of Pocket Expenses and that the expenditure claimed and receipted is reasonable and is authorised for
payment.
Signature of Authoriser Date
Certification by Claimant
2 0
I certify that the items claimed are due to me
Name of Authoriser Job Title
Signature of Claimant Date
2 0
PAY14 v.1.2 Page 1 August 2006
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