SECTION A - Personal & vehicle details please complete in block capitals
Full Name	Vehicle Reg. No.
Department (SU Staff & Students only)	Claimant’s reference
Address to which Remittance Advice is to be sent (Non-Staff and Visitors only) ………………………………………… ………………………………………… ………………………………………… …………………………………………	Please tick appropriate box Vehicle owned by me Vehicle owned by University Vehicle hired by University Health Science staff on protected NHS rates
Post Code
E-mail address	TO BE COMPLETED BY SU STAFF & STUDENTS ONLY	TO BE COMPLETED BY VISITORS AND OTHER NON-STAFF CLAIMANTS ONLY
Tel / Ext No	Staff No	Bank Sort Code
Student No	Bank Account No
Account Holders Name
The following sub codes must be used where appropriate
5830 SU Staff UK Travel & Subsistence	5870 SU Staff Training	5900 UK Travel & Subsistence (Non SU Staff & Students)	5850 Conference Expenses
5840 SU Staff Overseas Travel & Subsistence	5890 Entertainment & Hospitality	5910 Overseas Travel & Subsistence (Non SU Staff & Students)	Other codes must be specified
SECTION B - SUMMARY OF EXPENSES CLAIMED (FULL DETAILS TO BE PROVIDED OVERLEAF & original RECEIPTS ATTACHED)
Sub-Project	Account	Description	£	p
Total
Less Advance Received
Balance Claimed
SECTION C - Declaration and Certification
Declaration I declare that the expenses claimed are in accordance with the approved scales of payment as set out in section E8 of the University’s Financial Policies and Procedures and that no other claim has been or will be made for this expenditure against the University or any other organisation. The claim for subsistence does not exceed the actual costs incurred. Where I have used my own vehicle on University business my insurance policy covers me for business use. ……………………………………………… Claimant’s Signature Date…………….	Certification I certify that the expenses claimed were necessarily incurred on University business and comply with the University’s approved scheme for the reimbursement of travel & subsistence expenses. Where receipts are required under the University’s Financial Policies & Procedures I confirm that the original copies are attached, have been checked and are legitimate. ………………………………………………… Authorised Signatory’s Signature Date………………..
SECTION D - Finance Department Use Only
Advance Number	Batch Number
Exchange Rate	Passed By
Remittance Advice Details	Creditor Number

SECTION E - TRAVEL & EXPENSES DETAILS - EACH ELEMENT OF THE CLAIM SHOULD BE SEPARATELY ITEMISED (ORIGINAL RECEIPTS MUST BE ATTACHED)
Date	Start Time	Departure from (home or office)	Place(s) Visited	Purpose of Visit / Expenses	Finish Time	Return to (home or office)	Mileage Claimed <120 Miles	Mileage Claimed >120 Miles	Subsistence, Hospitality & Other Expenses
£	p
Total Mileage
p per mile	45p	13p
Sub Total	A	B
Total subsistence, hospitality & other expenses claimed
Total Mileage Claimed equals A + B
Grand Total

SECTION F – HOSPITALITY & ENTERTAINMENT – THE FOLLOWING ADDITIONAL INFORMATION MUST BE PROVIDED FOR HM REVENUE & CUSTOMS PURPOSES
Date	Reason for Hospitality	Name	Organisation	Name	Organisation	Name	Organisation