Expenses Claim Form
Name
*
First Name
Last Name
Is this a DA Community Interest Company expenses claim from the Charity?
Yes
No
Is any part of this claim for the Community interest Company? (i.e non Charity related).
Yes. If you have selected yes, press next at the bottom of this page.
No
Week commencing
-
Month
-
Day
Year
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.
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General Expenses - Describe these expenses below:-
Expense
Amount
Vat amount (leave blank if zero)
1
2
3
4
5
6
7
8
9
Amount in £&P
Printing expenses
Group Activities
Promotional work
Information/office
Other
Number of sheets printed @ 5p each
Amount in £&P
Total Claim for General Expenses £&P
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Are you claiming any mileage expenses that you intend to donate back to the charity and Gift Aid
*
No
Yes. If you answer yes, just press next
Mileage Expenses (not for transporting members) - List your journeys below:-
Journey type
Miles being claimed
1
Picking up supplies
Travel to a group (You can't claim this if you are paid to be in a group)
Home Visit
Trustee Meeting
Other work related mileage
2
Picking up supplies
Travel to a group (You can't claim this if you are paid to be in a group)
Home Visit
Trustee Meeting
Other work related mileage
3
Picking up supplies
Travel to a group (You can't claim this if you are paid to be in a group)
Home Visit
Trustee Meeting
Other work related mileage
4
Picking up supplies
Travel to a group (You can't claim this if you are paid to be in a group)
Home Visit
Trustee Meeting
Other work related mileage
5
Picking up supplies
Travel to a group (You can't claim this if you are paid to be in a group)
Home Visit
Trustee Meeting
Other work related mileage
6
Picking up supplies
Travel to a group (You can't claim this if you are paid to be in a group)
Home Visit
Trustee Meeting
Other work related mileage
7
Picking up supplies
Travel to a group (You can't claim this if you are paid to be in a group)
Home Visit
Trustee Meeting
Other work related mileage
8
Picking up supplies
Travel to a group (You can't claim this if you are paid to be in a group)
Home Visit
Trustee Meeting
Other work related mileage
9
Picking up supplies
Travel to a group (You can't claim this if you are paid to be in a group)
Home Visit
Trustee Meeting
Other work related mileage
Total miles being claimed:-
Amount in £&P (45p per mile).
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Are you claiming any mileage expenses that you intend to donate back to the charity and Gift Aid
*
No
Yes. If you answer yes, just press next
Mileage Expenses for the volunteer transporting of a member
Members being transported
Mileage claimed
1
2
3
4
5
6
7
8
9
Total miles being claimed:-
Amount in £&P (45p per mile).
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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
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Grand Total (including 3rd party payments).
VAT, any VAT paid must be backed up by a VAT receipt
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Please upload receipts, invoices and any other evidence. (All to be dated within 30 days of this claim, unless agreed by Dementia Active)
Browse Files
Drag and drop files here
Choose a file
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of
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Signature
*
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 (nos. only , no hyphens)
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Submit
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