Teaching Staff Claim Form

Tick if this is your first claim / Tick if this is your final claim
Please tick if you are paid* / Paid on 17th / Paid on 23rd
Surname* / Forename* / Title* / Emp No.*
School* / Month* / Year*
Tick claim types below as appropriate*
A. / Supply Teacher Claim - to be entered as decimal days overleaf *
B. / 1 to 1 Tuition @ £25.66 per hour - to be entered as decimal hours overleaf*
C. / Teacher employed as lunchtime supervisor - to be entered as decimal hours overleaf*
Note:
1.  If this is your first claim please complete all details below, failure to do so may delay payment
2.  If there is any change to your details please complete only the relevant section
Date of Birth* / National Insurance No.* / TRN No.*
Address*
Post Code*
Bank / Building Society Name* / Sort Code*
Branch* / Account Number*
Note: Complete daily claims overleaf, total days worked at each school and transfer to boxes below
Totals brought forward
Claim Type* / Payroll use only PEID / Total Dec Hours / Total Dec Days* / Hourly / Daily Rate Payable* / Account Code* / Cost Centre*
A – Supply Teacher / 1510 / . / .
A – Supply Teacher / 1510 / . / .
A – Supply Teacher / 1510 / . / .
A – Supply Teacher / 1510 / . / .
B – 1 to 1 Tuition / 7000 / . / .
B – 1 to 1 Tuition / 7000 / . / .
B – 1 to 1 Tuition / 7000 / . / .
C – Supervisory Assistant / 2730 / . / .
C – Supervisory Assistant / 2730 / . / .
C – Supervisory Assistant / 2730 / . / .
Total Decimal Days / Hours * / . / .
As claimant I certify that I have worked the days shown overleaf. I understand that any deliberate entry of false information will be regarded as gross misconduct
Employee’s Signature:* / Date:*
Details of Claim
Date* / School* / Claim type* / No of Decimal Hours / Days* / Hourly / Daily Rate Payable* / Account Code* / Cost Centre* / Authorised
Sign & print name*
. / .
. / .
. / .
. / .
. / .
. / .
. / .
. / .
. / .
. / .
. / .
. / .
. / .
. / .
. / .
. / .
. / .
. / .
. / .
. / .
. / .
. / .
Aggregate per Claim Type / Cost Centre and transfer totals overleaf* / . / .
. / .
. / .
. / .
. / .
* Mandatory field
Please retain a copy for your own personal records. / 2 of 2 / Ref No: F16
Version: 1.1
Version Date: 02/04/2013