LIVING AWAY FROM HOME DECLARATION

I, _______________________________________________________ declare that:

during the period _____________________to________________________
I was required to live away from my usual place of residence in order to perform the duties of my
employment and that during that period my usual place of residence was
___________________________________________________________________________________
___________________________________________________________________________________
(state place where you usually live)
and during the period the place at which I actually resided was
___________________________________________________________________________________
___________________________________________________________________________________
(state all addresses at which you resided while away from home during the period)
(Only include if also receiving a food component in the allowance)
I also declare that I received an allowance of $__________________/week during this period which
represented compensation for my increased cost of expenditure on food.

Signature_______________________________________
Date__________________________________________