DEPARTMENT OF EDUCATION AND SCIENCE (TRAVEL & SUBSISTENCE EXPENSES CLAIM FORM) (1) N A M E ( B L O C K C A P I T A L S ) HOME ADDRESS: OFFICE ADDRESS (2) DETAILS OF CAR (if used) (3) DETAILS OF CLAIM PURPOSE OF JOURNEY: DATE DEP. ENGINE C.C. INSURANCE CO. TIME OF RET. FROM JOURNEY TO Jh JoAfl 1 QH-UD buk^t faU + ikfijDrv ait -co M.ov ML. t TA>>#* t&k U- tx* huLLifiiMtoXttoAo* MODE (car or public transport) KM RATE PER KM COST SUBSISTENCE (ind. public EXPENSES transport cos) (RATE) -- -- S3-6/ --- /< to -- - -- 23-6; -- -- (o, io 0 SUB. TOTALS GRAND TOTAL LESS IMPREST (IF ANY) TOTAL PAYMENT IF MEALS OR ACCOMMODATION WERE PROVIDED FREE OF CHARGE PLEASE GIVE DETAILS: (4) DECLARATION BY CLAIMAINT: I declare lhat: (a) ,t>) (d) (e) The subsistence and other allowances that I claim are corred according to the relevant regulations. The expenses were necessarily incurred in public, services only. ( c ) The vouchers attached are correcl I have not claimed, nor will I daim from any Government Department, nor from any other source, the expenses incurred above during this period The car (details above) is owned and maintained by me and is, and will continue to be. insured by me for the purposes of the Road Traffic Acts and I win advise the Department of any change to the insurance cover. SIGNATURE (of Claimant) SECTION AND LOCATION: ) jrtADE DATE EXTN.: (5) APPROVAL OF CLAIM I certify that: (a) (b) ( c) The particulars furnished are correct and in accordance with relevant regulations. The journeys were in accordance with a programme of wor1< designed to reduce travelling to a minimum consistent with effidn icy. This daim is to be charged to COST CENTRE 1 SIGNATURE (of c e r t i f y i n g o f f i c e r ) GRADE Ckl. For payment DATE AMOUNT EUR SUBHEAD CODE EXTN.: for In Tr|vl 10 /ofrjl .-- / o i - -- o-- -- -- - -- SUB. TOTALS WHERE SUBSISTENCE IS CLAIMED EXACT TIME OF DEPARTURE & RETURN MUST BE SHOWN GRAND TOTAL LESS IMPREST (IF ANY) TOTAL PAYMENT IF MEALS OR ACCOMMODATION WERE PROVIDED FREE OF CHARGE PLEASE GIVE DETAILS: (4) DECLARATION BY CLAIMAINT: I declare thai: (a) b) (d) (e) The subsistence and other allowances that I claim are correct according to the relevant regulations, The expenses were necessarily incurred in public services only ( c ) The vouchers attached are correci I have not claimed, nor will I daim from any Government Department, nor from any other source, the expenses incurred above during this period The car (details above) is owned and maintained by me and is, and will continue to be, Insured by me for the purposes of the Road Traffic Acts and I will advise the Department of any change to the Insurance cover. f ^ L GRADE DATE 3 0 SIGNATURE (of Claimant) SECTION A N D LOCATION: / t o f a Off**-- ttJfL EXTN.: 2-\ (5) APPROVAL OF CLAIM I certify that: (a) (b) ( c) The particulars furnished are correct and in accordance with relevant regulations. The Journeys were in accordance with a programme of work designed to reduce travelling to a minimum consistent with effici mcy. This daim is to be charged to COST CENTRE SIGNATURE (of c e r t i f y i n g officer) GRADE DATE At ft EXTN.: AMOUNT EUR_ SUBHEAD CODE Date Dolo COST CENTRE DEPARTMENT OF EDUCATION AND SCIENCE (TRAyEL & SUBSISTENCE EXPENSES CLAIM FORM) (1) N A M E ( B L O C K C A P I T A L S ) ' HOME ADDRESS: OFFICE ADDRESS (2) DETAILS OF CAR (if used) (3) DETAILS OF CLAIM PURPOSE OF JOURNEY: (purpogfl ENGINE C.C. INSURANCE CO. DATE DEP. TIME OF RET. FROM JOURNEY TO MODE (car or public transport) KM RATE PER KM 5 COST SUBSISTENCE (ind. public EXPENSES transport cos < (RATE) toft-fi 3 3 t>\ 13-7/ } ? i) 0 GRAND TOTAL LESS IMPREST (if AMY) IF MEALS OR ACCOMMODATION WERE PROVIDED FREE OF CHARGE PLEASE GIVE DETAILS: (4) DECLARATION BY CLAIMAINT: I neclare that: (a) (b) (d) (e) The subsistence and other allowances that I claim are correct according to the relevant regulations. The expenses were necessarily incurred in public services only. above during this period The car (details above) is owned and maintained by me and is. and will continue to be. insured by me for the purposes ol Ujfe Road Traffic Acts and I wilt advise the Department of any change to the insurance cover SIGNATURE ( o f Claimant) SECTION A N D LOCATION: TOTAL PAYMENT ( c ) The vouchers attached are correct I have not claimed, nor will I claim from any Government Department, nor from any other source, [he expenses Incurred GRADE DATE EXTN.: (5) APPROVAL OF CLAIM I certify that: (a) (b) ( c) The particulars furnished are correct and in accordance with relevant regulations. The journeys were In accordance with a programme of work designed to reduce travelling to a minimum consistent with effici ncy This claim is to be charged to COST CENTRE M SIGNATURE ( o f c a m f y l n g officer) GRADE DATE 10 EXTN.: s=s==s=5s=asssaMBS5=BaBSss=s: Examined sssnsaissEsss Cld. For payment AMOUNT EUR_ SUBHEAD CODE Date Dale COST CENTRE DEPARTMENT OF EDUCATION AND SCT^NCEr (TRAVEL & S U B S I S T E N C E E X P E N S E S CLAIM FORM) (1) NAME (BLOCK CAPITALS) cau. 5 HOME ADDRESS: (2) DETAILS OF CAR (if used) ENGINE C . C . . INSURANCE CO. (3) DETAILS OF CLAIM PURPOSE OF JOURNEY: i-it'0 b M,\) (O,, ; /u A) "WHERE SUBSISTENCE IS CLAIMED EXACT TIME OF DEPARTURE & RETURN MUST BE SHOWN GRANDTOTAL LESS IMPREST (Many) IF MEALS OR ACCOMMODATION WERE PROVIDED FREE OF CHARGE PLEASE GIVE DETAILS: (4) DECLARATION BY CLAIMANT: TOTAL PAYMENT c : I declare that: (a) b aat ' C'aim fr t The subsistence and other allowances that I claim are correct according to the relevant regulations The expenses were necessarily incurred in public services only. (c) The vouchers attached are 'correct during'thiVpertaf' ?m G o v e r n m e n ' Department, nor from any other source, the expenses incurred ehov>> (e) The car (details above) is owned and maintained by me and is. and will continue to be insured by me for the purposes of the Road Traffic Acts and I will advise the Department of any change to the Insurance cover. GRADE DATE <*L ( EXTN.: __ SIGNATURE (of C l a i m a n t ) . jSECTION A N D LOCATION: : Jlik }> >> << - >> << >> o GRADE -- 6jlQ.fl * 222-,) EXTN.: SIGNATURE (of c e r t i f y i n g o f f l c e r ) ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ DATE = ' Examined CM. for Payment AMOUNT EUR Date: SUBHEAD CODE Date COST CENTRE D E P A R T M E N T OF E D U C A T I O N A N D S C I E N C E (TRAVEL (1) N A M E ( B L O C K C A P I T A L S ) EXPENSES CLAIM FORM) HOME ADDRESS OFFICE ADDRESS (2) DETAILS OF CAR (if used) (3) DETAILS OF CLAIM PURPOSE OF JOURNEY: (puroiM* ol <<>>en ftrnty tnmild ho nhnwi) ENGINE C.C. INSURANCE CO. JOURNEY FROM TO j y t .ucjkJ* M*. QeJt Uu/A^j . G r t tkfjQejt-l ^M^j-MoiK J2. Qftt ibrtjjd ^ MODE (car or public transport) KM RATE PER KM COST (ind. public transport cosi SUBSISTENCE EXPENSES (RATE) fa 3b?1 u 12> --SUB.TOTALS SERE SUBSISTENCE IS CLAIMED EXACT T I M ^ F DEPA DEPARTURE?* RETURN MUST BE SHOWN GRAND TOTAL LESS IMPREST (IF ANY) TOTAL PAYMENT IF MEALS OR ACCOMMODATION WERE PROVIDED FREE OF CHARGE PLEASE GIVE DETAILS: (4) DECLARATION BY CLAIMAINT: I declare that: (a) (b) (d) (e) The subsistence and other allowances that I claim are correct according lo the relevant regulations. The expenses were necessarily incurred in public services only. ( c ) The vouchers attached are correct I have not claimed, nor will I daim from any Government Department, nor from any other source, the expenses incurred above during this period The car (details rocl/e) is owned and maintained by me and is. and will continue to be. Insured by me for the purposes pfjhe Road Traffic Acts and I will advise the Department of any change to the insurance cover. -Am loaW o / SIGNATURE (of C l a l m a n H J ^ ^ P SECTION AND LOCATION: GRADE DATE EXTN.: (5) APPROVAL OF CLAIM I certify that: (a) (b) (c) The particulars furnished are correct and in accordance with relevanl regulations. The )oumeys were in accordance with a programme of work designed to reduce travelling lo a minimum consistent with effick> icy. This daim is to be charged to COST CENTRE SIGNATURE (of certifying offlcor) i M t o GRADE DATE EXTN.: ========== : :s For m a In Horn* T r a w l : Examined Cld. For payment AMOUNT EUR SUBHEAD CODE Date Date COST CENTRE DEPARTMENT OF EDUCATION AND SCIENCE i J R A V E ^ ^ l B S I S T E N C E E X P E N S E S CLAIM FORM) (1) NAME (BLOCK CAPITALS) HOME ADDRESS: Fi,. (2) DETAILS OF CAR (If used) ENGINE C.C. INSURANCE CO. (3) DETAILS OF CLAIM PURPOSE OF JOURNEY: DATE DEP. VMF. rt'M. (piTfpo>> of Men lourray n i d b. u*mn) D R.I J t A/.Cr M| D^Iv.'M To To D Hlkt* \ 0 P"1 W ( t Kkouj 1 u -- D ftO CrH L r ,^n ^ " fI O r (TM) is. and will continue to be, insured by me for the purposes of the Road Traffic Acts and I will advise the Department of any change to the ins Insurance cover. d maimained and SECTION AND LOCAT.ON: M , l l f t ( Q ^ ^ S Q f f , l ? ( 5 ) A P P R O V A L OF C L A I M I certify that: (a) The particulars furnished are correct and in accordance with relevant regulations s - S K E S S K s r : m w r * * = * * = * >> , o << -- << - * << * - nsistent rith efficiency. SIGNATURE (of c e r t i f y i n g o f f i c e r ) . GRADE DATE EX N.: Fo.r_USeJnJBUB.i.SBCtJon: Examined CId. for Payment AMOUNT EUR SUBHEAD CODE DatB: Date COST CENTRE