Car Lease Consent Form by rtu12219

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Car Lease Consent Form document sample

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									<<Please type your employers name here>>
                                                                                                             --- STRICTLY NOT FOR PAYMENT---
LEASE CAR MILEAGE RECORD

Name ....................................................... Payroll Number..............................................,Lease car Ref ...........................................................
Dept ............................................................Month Ending...................................................Vehicle Reg No .........................................................
Agreed Excess Miles.........................................Return Home to Base miles ...........................................


1. Claims must be submitted monthly to the appropriate officer for certification.                         Start mileometer reading:           ..................................................
2. FULL details of each journey are essential.
3. Official journeys MUST NOT include home to base mileage.                                               To agree with the closing reading on previous claim




                            Journey                             Journey                    Official
    Date                                                                                    Miles Details of journey
                              From                                  To                     Claimed




                                                                       Total C/F
                                     Journey                                        Journey                          Official
      Date                                                                                                            Miles Details of journey
                                       From                                               To                         Claimed




                                                                                                                              Total Business Miles
ONLY complete this section if excess mileage has been approved.
Excess journeys No..................@ ....................miles =

CERTIFICATE TO BE SIGNED BY CLAIMANT
I CERTIFY THAT:
The journeys to which this record relates were official journeys that were wholly and                                         FOR COMPLETION BY CLAIMANT
exclusively incurred by me in the course of my official duties and for the purpose stated.
W here I have included home to base miles in respect of emergency recalls to duty or returns
out of hours, i certify that i had accepted responsibility for the situation leading to the recall                            Mileometer reading at end of month......................................
before leaving home. I have carried out daily & weekly checks on the engine oil & coolant
levels and tyre pressures. I have also checked the brakes, lights and battery condition. The
vehicle servicing and maintenance is up to date.                                                                              Mileometer reading at start of month.....................................

This claim relates to expenses actually and necessarily incurred in connection with my
employer detailed at the head of this form. No claim has been made or will be made by me
                                                                                                                                                        Total miles ...........................................
on any other Public Body or Organisation for expenses or allowances in connection with the
business stated. I have not previously claimed for any item on this claim and that each
journey was performed in the most economical manner and the information stated is to the                                      Less business mileage for month............................................
best of my knowledge and belief correct. I understand that it is a serious offence to make or
conspire to make any false statement on this claim or to withhold any information relevant to
this claim certificate, and that such an offence could lead to disciplinary action and I may be                                        Private mileage for month.........................................
liable for prosecution and civil recovery proceedings. I consent to disclosure of information
from this form to and by my employer and any other party my employer requires for the
purpose of verification of this claim, prevention, detection and prosecution of fraud.


                                                                                                                                 --- STRICTLY NOT FOR PAYMENT---
                                                                                                                              Notes: This form should not be used for claims for subsistence,
Signature ................................................................ Date .................................                     travel by public transport or course expenses.


CERTIFICATION
I CERTIFY that, to the best of my knowledge and belief, the
claimant was engaged on the duty stated on the dates shown.
Signature ................................................................. Date ................................


Designation ......................................................................................................


PLEASE SEND THIS COMPLETED FORM TO:
KNOWLES ASSOCIATES, RED LION HOUSE, GREAT BENTLEY, COLCHESTER, ESSEX, CO7 8QG

								
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