CLAIM FORM
Please complete the form below to submit your claim.
Expenditure Claimed
Ref. Expenditure Item Procurement Route Supplier Invoice No Invoice Date Defrayal Date Payment Ref. Gross Value VAT Claim Value Comments
1
£
£
£
£
Eligible Expenditure
£
Expenditure Item Cap / Rev Total Approved Costs Total project spend to date as agreed by CC - not inc. this claim Expenditure Claimed in this Claim Total Spend + Expenditure in this Claim Balance available Not to exceed total costs approved
Financial Declarations
You should only be claiming for items exactly as detailed in the procurement section of your grant offer letter. If any items being claimed or suppliers used have changed, please provide details here. Please also explain why an agreement to vary these was not obtained prior to the items being purchased.
If you have overspent by more than 10% on the cost of individual approved items, please explain why.
Please confirm whether your VAT status has changed since you submitted your application
Please confirm you understand you need to keep all original documentation relating to the project until dd/mm/yy as outlined in section xx of your contract. (date/section to be provided)
Please confirm that the bank account used for defrayal is the same one as declared on your New Supplier Form, is this is not the case please explain why.
I have complied with the programme requirements as set out in the Offer Letter.
Please confirm there is no relationship between your business and any of the suppliers used. If this is incorrect, please provide details.
Assets
You will need to complete the following Asset & Disposal Register for each capital item purchased.
If you are unable to complete the Register now, please provide an explanation as to why and indicate when you will be able to complete it.
Have you any plans to dispose or change the use of any assets purchased with Town Deal funds?
Asset Name and Description Serial or identification number Location of the asset Purchase price (£) (net recoverable VAT) Date of acquisition ownership? Details of any charges (where relevant) Method of Depreciation Date of Disposal if applicable
£
Project Progress
Please provide an update on progress to date
Outputs
Milestones/Timescales
Please report on your progress against the milestones agreed for the project as set out in your offer Letter. If there has been a delay inert a revised date by which you expect to achieve it by and explain the reasons for this.
Milestone Forecast Achievement Date Actual Date Achieved Comments