Self Managed Personal Budget 4 Weekly Declaration – Employers Name Clients Name (if different) Personal Assistant 1 Name - Worked Holiday Worked Holiday Mileage Respite Respite Hours Hours Nights Nights Hours Nights Personal Assistant 2 Name - Worked Holiday Worked Holiday Mileage Respite Respite Hours Hours Nights Nights Hours Nights Personal Assistant 3 Name - Worked Holiday Worked Holiday Mileage Respite Respite Hours Hours Nights Nights Hours Nights Comments/Notes I authorise for the above details to be paid to my Personal Assistant(s) for the work carried out over the above in line with the agreed Self Managed Personal Budget. 4 week period I can confirm that my Personal Assistant(s) do not work seven days per week and I have retained accurate records of the days and times which have been worked for reference. Employers Signature __________________________Date________ Please send completed Declarations to: Stockton Personalisation Support Service, 1st Floor, Queensway House, Billingham, TS23 2NF. E-mail:
Self Managed Personal Budget – 4 Weekly Declaration Employers Name Clients Name (if different) Personal Assistant 1 Name - Worked Hours Holiday Hours Worked Nights Holiday Nights Mileage Respite Hours Respite Nights Personal Assistant 2 Name - Worked Hours Holiday Hours Worked Nights Holiday Nights Mileage Respite Hours Respite Nights Personal Assistant 3 Name - Worked Hours Holiday Hours Worked Nights Holiday Nights Mileage Respite Hours Respite Nights Comments/Notes I authorise for the above details to be paid to my Personal Assistant(s) for the work carried out over the above 4 week period in line with the agreed Self Managed Personal Budget. I can confirm that my Personal Assistant(s) do not work seven days per week and I have retained accurate records of the days and times which have been worked for reference. Employers Signature __________________________Date________ Please send completed Declarations to: Stockton Personalisation Support Service, 1st Floor, Queensway House, Billingham, TS23 2NF. E-mail: