Note: Failure to Complete Theinformationbelowwillresult in the Claimbeingreturned to You

HEE NWOTrainees (LET -North Western)

TravelClaim For Excess Miles Only(Includingexcess authorisedat standardrates)

Name:Address:

Assignment No:

VehicleMake/Model:

C.C:RegistrationNo:

Mandatory Details Required

Note: Failure to complete theinformationbelowwillresult in the claimbeingreturned to you.

Whereis placeof work?

Miles fromhome toplaceof work
Deduct statutory 11miles
Equals excess claimable- singlejourney
(Multiply x 2 forreturnjourney)
-11

Dates forwhichExcess TravelMileage is claimed

Note: Pleaseusea separateform foreachmonth.

EnterMonth:

Please enter the total number of single journeys made on each date of the month being claimed in the boxes below ie Enter 1 for a single journey, 2 for a return journey etc:

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
11 / 12 / 13 / 14 / 15 / 16 / 17 / 18 / 19 / 20
21 / 22 / 23 / 24 / 25 / 26 / 27 / 28 / 29 / 30
31
Authoriseddaily excess mileage:
TotalNumberof journeys claimed:
TotalNumberof miles claimed:
To ensure payment for the next pay period please submit claim by 6h of the month. Please submit claims on a regular basis. Claims more than 3 months old will be returned to your Trust and require further approval. Your Trust reserves the right to refuse payment on claims “out of time”.
Authorisedaccommodation expensesinlieuof excess mileage: / £

Evidenceof accommodation expensesattached:☐ YES

Note:Payments will not be made without evidence.

CertificationBlocks

I certify anddeclare that:

1) The expenses/allowances claimed are in accordance with the Lead Employer Removal and Expenses Policy and are in

respect of expenses actually and necessary incurred as stated.

2) No other claim has been or will be made by me for expenses/allowances in connection with mileage/allowances as stated.

3) The vehicle which I claimed mileage for was and is insured.

4) I hold a current, valid full driving license.

Signatureofclaimant:Date:

Authorising Officer:(Eg: Educational Supervisor,Medical StaffingOfficer, Directorate Manager),

Note:Bysigningthis form youare accepting thisclaim tobepaidandyourTrust/Organisation areliablefortheRe-Charge.

I certify to the best of my knowledge and belief that the claimant has made the journeys as specified above:

SignatureofAuthorisingOfficer:

AuthorisingOfficer

Title:

Date:

PleasePrintName:

Authorising Officer:claims over3months old(This must be theBudget Holder)

Note:Bysigningthis form youare accepting thisclaim tobepaidandyourTrust/Organisation areliablefortheRe-Charge.