Contractor Type of charge Amount of Date of Employee Name (if claim being Evidence provided (to confirm date Doc. Number charge receipt of made for financial loss of an and amount of charge and that it is a Ref. applied (£) BSO payment employee) direct impact of the payment failure) 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 TOTAL/SUB-TOTAL
Doc. Ref. Contractor Number Type of charge Amount of charge applied (£) Date of receipt of BSO payment Employee Name (if claim being made for financial loss of an employee) Evidence provided (to confirm date and amount of charge and that it is a direct impact of the payment failure) 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 TOTAL/SUB-TOTAL