Expenses Claim Form

Expenses Claim Form

This form can only be used for claims that are 100% related to the Charity. Any expenses incurred by the Community interest Company can be submitted on a different form.
Week commencing

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Your Position
Is this payment being made to a related party, i.e family or a partner? If so it will needs to be approved/agreed by a 'non related' Trustee. A PDF of this expenses claim is available via email to a 'non related' Trustee. There is an approval link in the PDF.
Name of Person Completing this form

First NameLast Name
Organisation claiming these expenses
Is your claim described below? If not LEAVE BLANK and work through the following categories on the next few pages and enter your expenses claim in the appropriate sections.
Is this expenses claim solely relating to DA Charity?
Which Centre or group are you claiming for?

Food for groups - Describe these expenses below:-

Rows	Expense	Amount	Vat amount (leave blank if zero)
1
2
3
4
5
6
7
8
9

Charity Vehicle maintenance, fuel and oil.

Rows	Expense	Amount	Vat amount (leave blank if zero
1
2
3
4
5

Car lease or rental of vehicles for transporting members

Rows	Expense	Amount	Vat amount (leave blank if zero
1
2
3
4
5

Printing Expenses

Mileage Expenses (not for transporting members) - List your journeys below:-

Mileage Expenses for the volunteer transporting of a member

Other purchases - Describe these expenses below:-

Rows	Expense	Amount	Vat amount (leave blank if zero)
1
2
3
4
5
6
7
8
9

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

Cancelof
Grand total to be paid in £'s & P
(Official Use) VAT to be reclaimed on this payment
Signature
ONLY USE THIS LINK FROM THE PDF, AFTER SUBMISSION

Trustee use only- Please approve or reject this claim here

Please make a note of the unique expenses claim code, when approving or rejecting this claim.

If the link doesn't work on your device copy and paste this link into your browser:-

https://form.jotform.com/253095670582059
Unique expenses claim code
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)
Should be Empty: