CLAIM FOR TRAVELLING AND SUBSISTENCE ALLOWANCES
Winchester and Eastleigh
Healthcare NHS Trust NHS Month of
(In block letters) Initials Surname
* New Details
CERTIFICATE OF CLAIMANT
I CERTIFY THAT Dr
1 The travelling and subsistence allowances claimed are in accordance with National Health Mrs
Service Regulations and Whitley Council Agreements and are in respect of expenses actually Ms
incurred whilst engaged on the business stated and have not been claimed elsewhere. Payroll Pay Point Personnel No (Details on your payslip)
2 The insurance policy current throughout this claim provided, whilst the vehicle was used on Address of claimant
official business, full third party insurance cover against risk or injury or death of
passengers and damage to property. I undertake to indemnify the Trust in respect of any claim
made against me for which my Insurance policy does not provided cover.
3 (i) On the occasions where by allowances are clamed I necessarily spent more on meals
than if I had been at my permanent station, and Dept Innovation and Development
(ii) Where an allowance for a period of more than eight hours is claimed, I necessarily
incurred expenditure on an additional meal. Headquarters
4 CERTIFICATE OF EMERGENCY CALL-OUT Post held Trainee Consultant Practitioner
I certify that advice on the handling of emergencies was given before starting my emergency Make of Vehicle
call out journeys and I accept full responsibility for those aspects appropriate to my duties from Engine Cubic Capacity
that time (journeys which I do not consider to qualify for tax relief are shown in the appropriate Registration No.
TAXABLE column). Return journey - home to HQ (miles) 18
NB. Please complete forms monthly
* Please mark by using two bold lines // thus in the column provided and information which has
CERTIFICATE OF HEAD OF DEPARTMENT changed since your last claim was submitted.
I confirm that the expenses and journeys claimed on the form were necessarily incurred by the Travel outside the Region should be claimed at the Public Transport rate unless additional
above on official duties that authorisation was given for the use of the vehicles on official expenditure (eg overnight subsistence) would be incurred.
business and that the mileage claimed is correct.
Excess travelling expenses following a change of headquarters, return to work outside normal
Signed Date hours, assisted travel and home to office mileage's are taxable.
The total of these columns must not exceed the
RAIL AND OTHER
lesser of the previous two columns.
PASSENGERS TRAVELLING TIME SUBSISTENCE
Destination & Particulars of Journeys. HQ to EXPENSES
Mileage must be based on shortest route the place OVERALL MILEAGE CLAIMED
DATE *Regular or Standard
words 'District', 'Local Running' are not visited & MILEAGE Public Transport Rate Train Amount
acceptable - actual details must be given return Name Miles Out In
Taxable Taxable Taxable Taxable £ p £ p
Totals 0 0 0 0 0 0.00 0.00
SPS Codes 5622 5632 5624
* Delete as applicable