Download Witness Expense Claim Form

Coroner's Court Witness
Claim for Loss of Earnings and Other Expenses
N.B. Please read notes of guidance overleaf before completing this form in
BLOCK CAPITALS
Name:
CASE
CODE
Payable To:
Payee Address:
Postcode: (mandatory)
Contact Tel. No.:
Bank Account No.: (mandatory)
Third Party Reference: (if
Sort Code: (mandatory)
Account name:
applicable)
To be completed by the applicant, if self-employed, or the Witness’ employer, as applicable
DAILY LOSS IF DETAINED
Gross Loss of Earnings
………………….……
Less Income Tax
.………………….…..
Less National Insurance
……………...….……
Net loss of Earnings
________________
I certify that the applicant named above will incur the loss of earnings as stated by attending H M Coroner’s Court
NAME OF COMPANY ……………..……………………………………………………………………………………….
ADDRESS, INCLUDING POSTCODE …………………….………………………………………….......................
………………………………………………………………………………………………………………………………..
JOB ROLE………………………………………………………..…………………..…..
DATE…………..………...
NAME…………………………………………………….. SIGNATURE………………..……………………………...
HALF
DAY
FOR CORONER USE:
FULL
DAY
TOTAL LOSS OF
EARNINGS:
£
P
Give full details on continuation sheet & attach receipts.
NOTE: payment will not be made without receipts and is subject to maximum
limits set by the Ministry of Justice
FOR COMPLETION BY AUTHORISING OFFICER
NOTE: payment is subject to maximum limits set by the Ministry of Justice
FOR COMPLETION BY AUTHORISING OFFICER
NOTE: payment is subject to maximum limits set by the Ministry of Justice
Out of Pocket Expenses
Loss of Earnings
Total Claimed
TRAVEL
Fares:
Give full details on continuation sheet
an attach receipts
DETAILS OF DAILY TRAVEL
STARTING
DESTINATION
POINT
Mileage:
HOME
POSTCODE
MODE
INQUEST
POSTCODE
RETURN
JOURNEY MILEAGE
DAILY COST
£
P
£
P
TOTAL TRAVEL COSTS:
Name of Deceased …………………………………………
Date of Coroner’s Court(s) ………………………………..inc.
I certify that I have incurred the expenditure as described above as a witness for …… days at (a) Coroner’s Court (s) held
from………………..………………….…..to……………………..……………..…..inclusive and attach receipts where appropriate.
Signature of claimant ………………………………………………..
Subjective
3
7
0
Cost
3
G
P
C
R
Centre
0
Amount
Excl. VAT
Analysis
0
0
0
8
8
8
Date ……………………………………
VAT
Incl.
VAT Amount
TOTAL PAYABLE
9
Approving Officer to Complete the Section Below
I certify the attendance and approve the claim for a payment. The amounts claimed are calculated correctly and are within
the limits prescribed
Approving officer’s name………………..……………………………………… Date…………………………….……....…
Signature…………………………………………………….…………………… Contact tel. no……………………...…….
Coroner’s Court Witness Claim for Loss of Earnings and Other ExpensesContinuation Sheet
NAME:__________________________ DATE OF ATTENDANCE:____________
Date
Item
Cost
Receipt (Y/N)