Travelling Subsistence Claim Form Month Year

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Travelling Subsistence Claim Form Month Year Powered By Docstoc
					Travelling & Subsistence Claim Form                                                                                             Month:                                       Year:
                                                                                                                                               Other Travelling Expenses
                                                                                     Car Mileage (No. of Miles)                                                                            Subsistence
                                                                                                                                               and Claims for Passengers
Date of Journey   Purpose   Details of Each Journey            Total Actual                       Claim
                                                                                                                                                                (T) Train      Time Spent on Official
                                                                                                                                                                (TX) Taxi            Business
                                                                Home to                                                         Public Rate        £                                                                   £
                                                                                                Home to Duty                                                   (TL) Tunnel
                                                                  Home        Official                          Excess Miles                                                    From             To
                                                                                                  Addition                                                     (P) Parking




                                                      Totals            0.0              0.0              0.0             0.0            0.0           £0.00                                                               £0.00




                                                                                 Page 1 of 11                                                                                                Printed Date: 3/16/2011
Travelling & Subsistence Claim Form                                                                                                                                Month:                                     Year:

Home Address:                                                                                                                        Base and Department

                                                                                                                                     Department number             408 Z                                      (4 digits on the front of payslip)


I DECLARE THAT:                                                                                                                      Name and Initials

Statement (a)   The Travelling Expenses and Subsistance Allowances claimed are in accordance with the terms and
                conditions of service determined from time to time and have not been claimed from any other authority; where Assignment Number                                                                                  (From Payslip)
                day Subsistence Allowances are claimed. I spent more on meals than if I had been at my permanent station
                and where an allowance for more than 8 hours is claimed I necessarily incurred expenditure on an additional
                meal.                                                                                                           PLEASE NOTE:                      YOUR CLAIM FORM WILL BE RETURNED IF ALL RELEVANT
                                                                                                                                                                   DETAILS ARE NOT FULLY COMPLETED
Statement (b)   The claim for mileage allowance is in respect of:                                   Is this a new
                                                                                                    claim for this
                cc Engine of Car:                                                                        car?
                Registration no:
                                                                                                                                          Your claim should be submitted by your Manager with their Department's Staff
                Make of Car:
                                                                                                                                                             Attendance Record on a monthly basis
                Model of Car:
                Year of Car:
                Fuel Type:
                                                                                                                                                                           FOR OFFICE USE ONLY
                This is my first claim for this car:


Statement (c)   To the best of my knowledge and belief my car is roadworthy and was roadworthy throughout the period                               From:                                               To:
                covered by the claim.
                   I declare this statement is correct


                                                                                                                                                                                 No. of               Cost
Statement (d)   My car is fully insured against Third Party risks, including legal liability to passengers and damage to property.                                                Miles            Per Mile        Total Cost
                My Insurance Company is unchanged.
                   I declare this statement is correct
                                                                                                                                                   Total Actual Home to Home       0.0                                  £0.00
                My Insurance Company has                                                                                                           Official                        0.0                                  £0.00
                changed to:
                                                                                                                                                   Home to Duty Addition           0.0                                  £0.00
                                                                                                                                                   Excess Miles                    0.0                                  £0.00
Signature:
                                                                                                                                                   Public Rate                     0.0                                  £0.00    Total No. of
Date:                                                                                                                                                                                                                           Days Claimed

I certify to the best of my knowledge and belief, the claimant was engaged on the duty stated on the                                               Sub Totals                      0.0                                 £0.00                  0
date(s) shown above.
                                                                                                                                     Date of Payment:                                     Audit:
Signature:                                                                                        Senior Officer

PLEASE PRINT NAME IN BLOCK LETTERS:




                                                                                                                           Page 2 of 11                                                                                           Printed Date: 3/16/2011
Official Mileage Matrix                                                                                                                                                                         Wirral Area
Carlett Park College                                                                                                                                                                          Matrix shows mileage
MRHA Hamilton House                                                                                                                                                                               for each way
Ashton House                     5.5
St Catherine's Hospital          5.5                                               2
Victoria Central Hospital    9.5 5.5                                               4 4.5 5.5
Clatterbridge Hospital         6 11                                                4   4   9
Arrowe Park Hospital         11    7                                               4   4 5.5                                                                    5




                                                                                                                  Victoria Central Hospital
                                                   MRHA Hamilton House



                                                                                        St Catherine's Hospital



                                                                                                                                              Clatterbridge Hospital

                                                                                                                                                                       Arrowe Park Hospital
                            Carlett Park College



                                                                         Ashton House
Official Mileage Matrix                                                                              Merseyside Area
Alderhey             5                                                                               Matrix shows mileage
Arrowe Park         14        14                                                                         for each way
Broadgreen           5         2          13
Chester             35        31          17            29
Clatterbridge       18        18           5            17          16
Halton              18        15          24            13          16          21
Leighton            51        47          41            45          26          38           35
Macclesfield        47        44          51            42          44          49           31         22
Nobles
Nuffield            19        31          21            29           3          18           17         25          44
Royal Liverpool      5         4          10             3          25          14           16         48          44                     29
Southport           18        24          30            25          48          33           33         59          55                     49           22
Warrington          18        14          32            12          24          29            9         30          26                     24           15              32
Whiston             10         6          19             7          27          32           11         41          37                     27            9              25                8




                                                                                                                                                    Royal Liverpool
                                                                            Clatterbridge




                                                                                                                 Macclesfield
                                       Arrowe Park

                                                     Broadgreen




                                                                                                                                                                                  Warrington
                                                                                                                                                                      Southport
                            Alderhey




                                                                                                      Leighton




                                                                                                                                         Nuffield
                                                                  Chester
                  Aintree




                                                                                                                                Nobles
                                                                                            Halton
Official Mileage Matrix                                                                                                                                                             Cheshire & Wirral Area
                                                                                                                                                                                    Matrix shows mileage for each way
Aqua House, Chester                                                20 19 37                                                                                            2 23                           8            7 37 16 20 29 19 16 16 22 35 21 31 19 23                                                                                                                                                                                                                                                                                                                                                                                 9 24 23
Arrowe Park Hospital                         20                                                        3 51 17 40 13 14 53                                                                                                                                                       5 36 49                                                                       4 33 33 39 50                                                                                                                                            2 46                                                  4 40 12                                                                                                 6 40
Ashton/Adcote/Kent House                     19                              3                                         52 18 41 13 15 53                                                                                                                                         4 37 49                                                                       2 33 33 40 50                                                                                                                                            4 46                                                  1 40 13                                                                                                 3 40
Barnabas Centre, Macclesfield                37 51 52                                                                                                  42 21 39 40                                                                                 1 47 18 15 50 25 25 23                                                                                                                                                                                                          1 52                                                             8 50 21 40 55 21
Bowmere Hospital, West Cheshire                        2 17 18 42                                                                                                                    26               5            4 45 12 23 32 14 19 19 25 42 14 38 17 26                                                                                                                                                                                                                                                                                                                                                                                 5 21 26
Catherine House/Eaton House, Crewe           23 40 41 21 26                                                                                                                                       28 28 22 36 15                                                                                                                   6 39 10 10                                                                                                    3 21 42 18 39 0.5 29 44 0.5
Cherrybank Resource Ctr, Ellesmere Port                8 13 13 39                                                                                                      5 28                                        3 40                                                          9 24 36 11 21 21 28 37 14 33 11 28 0.5 16 28
Chestergates                                           7 14 15 40                                                                                                      4 28                           3                        42 10 25 38 13 20 20 27 39 11 34 13 28                                                                                                                                                                                                                                                                                                                                                                       3 18 28
Clark House, Hulley Road, Macclesfield       37 53 53                                                                                 1 45 22 40 42                                                                                                                  49 18 16 52 25 25 24                                                                                                                                                                                          2 54                                                             9 52 22 42 57 22
Clatterbridge Hospital                       16                              5                         4 47 12 36                                                                                     9 10 49                                                                                  33 46                                                           5 30 30 36 47                                                                                                                                            5 42                                                  4 37                                                          9                                         9 37
Denton House, Northwich                      20 36 37 18 23 15 24 25 18 33                                                                                                                                                                                                                                              13 35                                                                    9                          9 12 17 38 13 35 16 25 40 16
Field House, Sandbach                        29 49 49 15 32                                                                                                                             6 36 38 16 46 13                                                                                                                                         44                                              9                          9                    6 15 50 12 48                                                                                                                                          6 28 38                                                                                                               6
Hamilton Square, Birkenhead                  19                              4                         2 50 14 39 11 13 52                                                                                                                                                       5 35 44                                                                                        32 32 38 49                                                                                                                             6 45                                                  2 39 11                                                                                                 2 39
Hawthorn Centre, CAMHS, Winsford             16 33 33 25 19 10 21 20 25 30                                                                                                                                                                                                                                9                        9 32                                                                                     1                    6 24 34 17 32 13 22 37 10
Kemple Unit, Winsford                        16 33 33 25 19 10 21 20 25 30                                                                                                                                                                                                                                9                        9 32                                                          1                                               6 24 34 17 32 13 22 37 10
Leighton Hospital                            22 39 40 23 25                                                                                                                             3 28 27 24 36 12                                                                                                                           6 38                                                          6                          6                                   22 41 18 39                                                                                                                             3 28 43                                                                                                               3
Macclesfield Hospital, Victoria Road         35 50 50                                                                                 1 42 21 37 39                                                                                                2 47 17 15 49 24 24 22                                                                                                                                                                                                                              51                                           7 49 21 39 54 20
Pensby Clinic, Pensby Road, Wirral           21                              2                         4 52 14 42 14 11 54                                                                                                                                                       5 38 50                                                                       6 34 34 41 51                                                                                                                                                             45                                   5 42 14                                                                                                 8 42
Soss Moss, Mary Dendy                        31 46 46                                                                                 8 38 18 33 34                                                                                                9 42 13 12 45 17 17 18                                                                                                                                                                                                          7 45                                                                           45 18 34 49 18
St. Catherine's Hospital                     19                              4                         1 50 17 39 11 13 52                                                                                                                                                       4 35 48                                                                       2 32 32 39 49                                                                                                                                            5 45                                                                39 11                                                                                     4 39
Stalbridge Road, Crewe                       23 40 40 21 26 0.5 28 28 22 37 16                                                                                                                                                                                                                                                     6 39 13 13                                                                                                    3 21 42 18 39                                                                                                                                                          29 44                                                                                                 1
Unity House, York Road, Ellesmere Port                 9 12 13 40                                                                                                      5 29 0.5                                    3 42                                                          9 25 28 11 22 22 28 39 14 34 11 29                                                                                                                                                                                                                                                                                                                                               16 29
Victoria Central Hospital/Highfield Ctr      24                              6                         3 55 21 44 16 18 57                                                                                                                                                       9 40 38                                                                       2 37 37 43 54                                                                                                                                            8 49                                                  4 44 16                                                                                                                      44
Wellington House, Delamere St., Crewe        23 40 40 21 26 0.5 28 28 22 37 16                                                                                                                                                                                                                                                     6 39 10 10                                                                                                    3 20 42 18 39                                                                                                                                          1 29 44




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Wellington House, Delamere St., Crewe
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Unity House, York Road, Ellesmere Port
                                                                                                                                                                                                                         Clark House, Hulley Road, Macclesfield




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           Victoria Central Hospital/Highfield Ctr
                                                                                                                                                                                    Catherine House/Eaton House, Crewe




                                                                                                                                                                                                                                                                                                                                                                           Hawthorn Centre, CAMHS, Winsford




                                                                                                                                                                                                                                                                                                                                                                                                                                                          Macclesfield Hospital, Victoria Road
                                                                                                                                                                                    Cherrybank Resource Ctr, Ellesmere




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Pensby Clinic, Pensby Road, Wirral
                                                                                                                                                  Bowmere Hospital, West Cheshire
                                                                                                                  Barnabas Centre, Macclesfield




                                                                                                                                                                                                                                                                                                                                             Hamilton Square, Birkenhead
                                                                                       Ashton/Adcote/Kent House




                                                                                                                                                                                                                                                                                           Denton House, Northwich




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Soss Moss, Mary Dendy


                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Stalbridge Road, Crewe
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              St. Catherine's Hospital
                                                                                                                                                                                                                                                                                                                                                                                                              Kemple Unit, Winsford
                                                                                                                                                                                                                                                                                                                     Field House, Sandbach
                                                                                                                                                                                                                                                                  Clatterbridge Hospital
                                                                Arrowe Park Hospital
                                          Aqua House, Chester




                                                                                                                                                                                                                                                                                                                                                                                                                                      Leighton Hospital
                                                                                                                                                                                    Chestergates
                                                                                                                                                                                    Port
Official Mileage Matrix                               Travel Matrix
                                                   Matrix shows mileage for
                                                           each way
                                       VCH   SCH   OXTON   WCH    EPH    CGH
Adcote/Ashton/Kent Hse                   4     1       1                           VCH   Victoria Central Hospital
Arrowe Park Hospital                     6     4       4    16      12        5    WCH   West Cheshire Hospital
Bebington Health Centre                  9     3       4                           EPH   Ellesmere Port Hospital
Bidston Clinic                           2     3       3                           SCH   St. Catherines Hospital
Bromborough Clinic                      10     6       7                           CGH   Clatterbridge Hospital
Brook House                             24    20      20     2      6         14
Clatterbridge Hospital                   9     4       4    12      8
Eastham Clinic (Bridle Rd)              12     8       8
Ellesmere Port Hospital (Cherrybank)    17    12      12     5                8
Eltham Green Clinic                      5     4       3
Field Road Health Centre                 2     6       5
Ford Health Centre (Fenderway)           4     3       3
Greasby Heath Centre                     6     6       5
Heswall Health Centre                    9     8       8
Leasowe Clinic                           3     6       6
Mill House                              23    19      19     2                14
Miriam Health Centre                     2     3       2
Moreton Clinic                           5     6       6
Neston Clinic                           13    10       9
New Ferry Heath Centre                   7     3       3
North Clinic                             3     3       2
Oxton Health Centre                      4     1            18      12        4
Pensby Clinic                            8     7       7
Prenton Health Centre                    5     2       2
Riverside Surgery                        6     2       2
Rowan House                             15    11      10     8       2        6
St Catherines Hospital                   5             1    18      12        4
Upton Clinic                             5     5       4
Victoria Central Hospital                      5       4    21      17        9
Vittoria Medical Centre                  3     2       1
Water Street Clinic                      1     3       3
West Cheshire Hospitalital              21    18      18            5         12
West Kirby Health Centre                 9     9       7
Whetstone Lane Health Centre             4     1       1
Young People’s Centre                   22    19      19     1      6         13
    Guidelines to Completing Travel Claim
    Information on the completion and submission of expense claims

    This does not override any of the regulations on the payment of travelling and subsistence claims and is a
    guide to the completion and submission of claims




    Claims must be submitted using the expense claim form on the WUTH Intranet. This can be found following _____ >
    ______ > _____>_______


    Claims must be authorised by Manager and enclosed with the monthly Staff Attendance Records (SAR’s). Claims
    forwarded directly to the Employment Services Centre will be returned

 Mileage is payable for journeys using the shortest possible route



    Home to duty mileage claimed in respect of on-call, overtime is payable at public transport rate and is taxable in
    accordance with the Inland Revenue regulations

 Mileage in connection with training is payable at public transport rate


 Mileage is payable for either base to place visited and return to base, or actual mileage travelled whichever is the least


    Example I – Base of Arrowe Park
         Arrowe Park > 5 miles > Clatterbridge > 5 miles > Arrowe Park
           Home > 3 miles > Clatterbridge > 3 miles > Home
           6 miles payable as less than the 10 official miles

    Example II - Base of Arrowe Park
        Arrowe Park > 5 miles > Clatterbridge > 5 miles > Arrowe Park
           Home > 2 miles > Arrowe Park > 5 miles > Clatterbridge > 4 miles > Home
          10 miles payable

 To see example of a correctly completed travelling expense form click on button

 Receipts must be attached, the exception being parking charges when a receipt is not available

 Inter hospital travel matrix attached

				
DOCUMENT INFO
Description: Medical Travel Allowance Claim Form document sample