Expenses Claim Form

Expenses Claim Form
Name*

First NameLast Name
Is this a DA Community Interest Company expenses claim from the Charity?

YesNo
Is any part of this claim for the Community interest Company? (i.e non Charity related).

YesNo
If you have answered yes to 'this is a claim for the Community Interest Company.' You can not use this form. Please click here instead.
Week commencing*

MonthDayYear
In what capacity are you making an expenses claim? (Only pick one role at a time).

Volunteer/ Staff driver transporting member(s)
Trustee/Patron (expenses incurred while carrying out trustee/Patron duties only).
Member of Staff or Volunteer, other than that of a volunteer driver.

Mileage Expenses - List your journeys below:-
What was your journey relating to?

Picking up suppliesTravel to a group (You can't claim this if you are paid to be in a group).Home visitTrustees meetingOther
Total miles being claimed:-
Amount in £&P (45p per mile).

Third party payments, (invoice to be uploaded in supporting evidence section). Who needs to be paid?
What is this payment relating to?
Their account name, no. and sort code.
Amount in £&P

Please upload receipts, invoices and any other evidence. (All to be dated within 30 days of this claim, unless agreed by Dementia Active)

Cancelof

Signature*

Clear
Bank account name where you wish your expenses to be paid. (If this is left blank, we will use the account we have on record). If this is your first claim please provide the information required below.
Account Name
Account Number
Sort Code
Should be Empty: