Camden & Islington NHS Foundation Trust - GENERAL EXPENSECLAIM FORM

(Fornon-Trust employees)

CLAIMAINT DETAILS
Title / Surname / Forename(s)
Home Address / Bank Account Details
Bank Account Number:
Sort Code:
Name of Bank:
Name of Account Holder:
Date / Start Point
(e.g. Base) / End Point (e.g. Base) / Details of journey or expense / Amount £ / Passenger name on journey (if applicable) / Receipts attached (Y/N) / If no, explanation why
Totals
AUTHORISATION (For completion by Manager and Claimant)
ClaimantDeclaration - 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 initial beside the reason.
Claimant Signature______Claimant 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 ACCOUNTS PAYABLE, 3RD FLOOR EAST WING, ST PANCRAS HOSPITAL, 4 ST PANCRAS WAY, LONDON, NW1 0PE

OR BY EMAIL TO

PLEASE ENSURE BANK DETAILS ARE PROVIDED. THE TRUST WILL ONLY REIMBURSE EXPENSES VIA A BACS PAYMENT

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