Form Hr 01- Application Form - Fees And Related Payments Page 3
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5A4 complex template
Section D
My details
Section G
Signature and authorisation
Please fill out the sections overleaf and ensure that you have
National Insurance number
Passport number
receipts for all expenses before you complete this section
I certify the following:
Date of birth (DD/MM/YYYY)
Gender
• the particulars on this form are correct
Male
Female
• the amounts detailed are in accordance with University and
Other
Mr
Mrs
Ms
Miss
Grant Regulations for the fulfilment of my duties/tasks
Surname as appears on birth certificate or passport
• any expenses have been actually and necessarily incurred by
me in the course of work for the University
• I have not been paid for this work already
First names as appears on birth certificate or passport
• I have not received payment for this work from any other
source, and if this happens in the future I will repay the
If you are related to a member of staff at the University, please
University
give their name below
•
any mileage allowance is claimed in respect of a vehicle for which
the necessary legal and insurance requirements have been met
Sponsoring School/Service
• in the event of discrepancies being found subsequent to
payment of this claim, I agree to repay any overpayment.
£
The total value I have
Fees
A
Home address
detailed overleaf is:
£
Expenses
B
£
Total
I claim for incidental expenses. These are detailed in
Section B and receipts are attached.
Postcode
Claimant’s signature
Contact details
Telephone
Email
DATED
You will be emailed a payslip. Take note of the password
Research supervisor or grant/contract holder’s signature.
UNIFEE which opens the attachment.
(Only necessary if claim is related to a research contract.)
Section E
Present circumstances
Research supervisor’s name
TO BE COMPLETED BY CLAIMANT
Please read the following statements carefully and tick ALL
those that apply to you
1 This is my first job since last 6 April and I have not been
DATED
receiving taxable Jobseeker’s Allowance or taxable
If you choose to use this form to pay monies to an individual
Incapacity Benefit or a state or occupational pension
for work done you must satisfy yourself that the person has
2 This is now my only job, but since last 6 April I have
the right to work in the UK. The documents that must be
had another job, or have received taxable Jobseeker’s
checked, prior to any work being done, can be found at
Allowance or Incapacity Benefit. I do not receive a state or
occupational pension
humres-document_check_guidance.pdf
3 I have another job or receive a state or occupational pension
I have examined this form and I confirm the claim is in
accordance with University policy and I authorise payment.
4 If you left a course of UK Higher Education before last 6 April
and received your first UK Student Loan instalment on or after
Head of School/Service or Nominee’s signature
1 September 1998 and you have not fully repaid your Student Loan
Section F
My bank details (highlight if changed)
DATED
Bank name
Authoriser’s name
PLEASE PRINT
DATED
Sort code/BIC code
Section H
Equal Opportunities monitoring
Account/IBAN number
Nationality
Building society roll number (if applicable)
Ethnicity
Disabled
Yes
No
3
The University will pay you direct into your bank account.
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