Claim Form Dementia Active CIC

Claim form

Click here to exit
Staff/ Volunteer name *

First Name Last Name
Week Commencing *

Month Day Year
Date
Tick here if you are claiming for mileage relating to the transportation of Member(s)

What mileage are you claiming for?

Picking up supplies Mileage to a group*, not including member transportation Meeting/Home visit
Mileage Breakdown, not including member transportation
Total mileage
Total in £'s and pence
Please breakdown any other expenses being claimed
Other expenses - total being claimed in £'s and pence
Upload receipts for other expenses

Browse Files

Cancel of
Printing - Number of sheets printed @ 5p per sheet
What was the printing for?
Printing - total being claimed in £'s and pence
Grand Total - in £'s and pence
Signature

Clear
(Official Use)

Tick once paid

Name of transported member(s)
Total mileage
Total being claimed in in £'s and pence
Please note this mileage is paid to you by Dementia Transport CIC, company no. 12902468
Signature

Clear
(Official Use)

Tick once paid

Please note all mileage and expenses claims must be made within 30 days of purchase/miles driven, unless agreed by Dementia Active. *Mileage to a group only payable if agreed by Dementia Active.
After submittion you will be able to claim other expences not related to member transport, if necessary.
Should be Empty: