Details of the claim Travel Expenses Start Location: Finish Location: Mode of transport: Public Transport £ (Receipts must be attached) Total Number of Miles:_____________@ 24p per mile Private Transport £ (Mileage will be calculated at quickest route) Name(s) of passenger(s):____________________ Passengers Total miles travelled with passenger ___________ (Reimbursed at 5p per £ (Passengers must be travelling to same event & also mile per passenger) entitled to reimbursement of travel expenses by HEKSS) Accommodation Expenditure £ Subsistence Meal Expenditure £ Please specify below: Other Expenses £ DETAILS OF CLAIM (ALL CLAIMS MUST BE ACCOMPANIED BY RECEIPTS) Please attach all receipts with your claim form securely. Please read the guidance notes you obtained along with this claim form very carefully. HEKSS reserves the right to reimburse the cheapest option wherever relevant. EVENT/ACTIVITY GP Selection Assessment Centre LOCATION HEE, Stewart House, 32 Russell Square □ DATE(S) Monday 26th September 2016 Amount Claimed Total Travel Reimbursement £ Claimant Declaration: I declare that the expenses claimed hereunder were necessarily incurred by me in attending the above event and are in accordance with the conditions governing the payment of travelling expenses attached. I understand that any fees are paid gross and that I am responsible, where appropriate, for declaring this income for tax purposes. Name: Signed: Date: Certification of Attendance: I have checked this claim and am satisfied that the claimant attended the event according to the information given and that the Total claimed is correct. Name: Teddy Abrokwa Signed: Date: This form then needs to be returned to the LETB for authorisation before submission to SBS Authorised By: Name: Sandra Forster Position: Primary Care Business Manager Department: Department of Postgraduate General Practice Education Signed: Date:
Details of the claim Travel Expenses Start Location: Finish Location: Public Transport Mode of transport: (Receipts must be attached) £ Private Transport Total Number of Miles:_____________@ 24p per mile (Mileage will be calculated at quickest route) £ Passengers (Reimbursed at 5p per mile per passenger) Name(s) of passenger(s):____________________ Total miles travelled with passenger ___________ (Passengers must be travelling to same event & also entitled to reimbursement of travel expenses by HEKSS) £ Subsistence Accommodation Expenditure £ Meal Expenditure £ Other Expenses Please specify below: £ DETAILS OF CLAIM (ALL CLAIMS MUST BE ACCOMPANIED BY RECEIPTS) Please attach all receipts with your claim form securely. Please read the guidance notes you obtained along with this claim form very carefully. HEKSS reserves the right to reimburse the cheapest option wherever relevant. EVENT/ACTIVITY GP Selection Assessment Centre LOCATION HEE, Stewart House, 32 Russell Square DATE(S) □ Monday 26th September 2016 Amount Claimed Total Travel Reimbursement £ Claimant Declaration: I declare that the expenses claimed hereunder were necessarily incurred by me in attending the above event and are in accordance with the conditions governing the payment of travelling expenses attached. I understand that any fees are paid gross and that I am responsible, where appropriate, for declaring this income for tax purposes. Name: Signed: Date: Certification of Attendance: I have checked this claim and am satisfied that the claimant attended the event according to the information given and that the Total claimed is correct. Name: Teddy Abrokwa Signed: Date: This form then needs to be returned to the LETB for authorisation before submission to SBS Authorised By: Name: Sandra Forster Position: Primary Care Business Manager Department: Department of Postgraduate General Practice Education Signed: Date:
HEE%20-%20SAC%202016%20Guidance%20and%20Claim%20Form%20(Sep%2016).docx