Camden & Islington NHS Foundation Trust - TRAVEL & EXPENSESCLAIM FORM

(For Trust employees on payroll only)

EMPLOYEE DETAILS
Title / Surname / Forename(s)
Assignment No. / ______-_ / Band / Grade / Job Title
Home Address / Base Address
(a) / (b) / (c) / (d) / (e) / (f) / (g) / (h) / (i) / (j) / (k)
Date / Start Point
(e.g. Base) / End Point (e.g. Base) / Details of journey / expense, include passenger names in brackets / Business Miles
(24p per mile) / Passenger miles / Excess Miles / Excess Costs / Public Transport Costs (train/tube/taxi /bus) / Parking Costs / Other Expenses
(Please specify)
Totals
AUTHORISATION (For completion by Manager and Employee)
Employee Declaration - I confirm that:
a)The mileage, expenses, and allowances claimed are accurate and were incurred on the duty stated and are in accordance with the Trust’s financial instructions and/or appropriate national/local terms and conditions.
b)These expenses have not or will not be claimed against another organisation.
c)I understand that if I knowingly provide false information this may result in disciplinary action and I may be liable for prosecution and civil recovery proceedings.
d)I consent to the disclosure of information from this form to and by C&I and the NHS Counter Fraud and Security Management for the purposes of verification of this claim and the investigation, prevention, detection, and prosecution of fraud.
e)I have attached all receipts required to prove costs for expenses. If receipts cannot be provided please state why and get your manager to sign beside the reason.
Reason no receipts:______Manager authorisation for no receipts:______
Employee Signature______Employee Print Full Name______Date______
Manager’s Certification - I certify that to the best of my knowledge and belief, the claimant was engaged on the duty stated on the dates shown and that the claims for expenses and subsistence are in accordance with the Trust’s financial instructions and procedures.
ManagerSignature______Date______
Manager Print Full Name______
Manager Telephone No.______Manager E-mail Address______ / Authorised Signatory Stamp and Financial Code

PLEASE SEND BY POST TO PAYROLL AT C&I PAYROLL TEAM, EQUINITI ICS, 205 AIRPORT ROAD WEST, BELFAST, BT3 9ED.

ONLY ORIGINAL PAPER FORMS WILL BE ACCEPTED - NO FAXES OR EMAILS. ANY AMENDMENTS WILL NEED TO BE INITIALLED BY MANAGER AND EMPLOYEE.