I

Accessto \t\lork

1ry5

SuPPort worker cloim

I'hffi.IftT.lIlI-

Deportment for
Workond Pensions
Pleose complete Ports 1 to 4 then send this form to the oddress ot Port 5.

your poyment deto.ils,hove chonged

- if this is your first cloim, or,New
or smended detoils' form.
for
s
pleose
osk
cloim,
your
lost
since

Importont

*, C

Title

Miss

ffTI{JNS

Surnome

AtW ref number

Use this form

"" I

loo?qo2-

to cloim for ony period

bt

A i F,N'n
V\

ILL

3o ID t:
to/rr.,/ t5

to
Hours cloimed

f\OTTTA,IU

(g oT fr11

sTf.rfeQ
cficlttN6

WILL

tt / rr /rs
ls /rLl ts

SFss lot\s

t!1LL

t\ tal'\r r

u"\UL

c lot ltS
i

wlltr
lr

Ar

rA

e uKe'fGD?B4ry'

trf.rcl'lN

I
Dote

l-l

Emqil sddress DBrrl6t

uP to o colendor month'

Hours cloimed

,rLKF+ o. 1i11{f.l

otn"r

Other nomes

tlo /

From

l-l "' f]

(,'

Dote

Hours cloimed

N YgT

)ffq
3

3
3

3
3

3
Totol hours
cloimed
Totol costs Poid
in this period

Agreed

fL5

I VhT

pleose ottoch originol receipts or invoices. If you do not hsve the originols,
qs
oi"or" ottoch .",iifi"d copies. Receipts must show o minimum: you
ore
of the support
dote
the
nome,
[n. o]nount poid, the support worker's
provided'
support
the
of
description
.loitning for, ond o

odditionolcosts
Employer

contribution
Amount cloimed

from
Access to Work

f
E

Contributions from your employer'

rnT

Add costs ond ogreed odditionol

costs, then deduct the emPloYer's

contribution.
Pleqse turn

over

lf you ore employed

Your employer should complete this port.

If you ore self-employed

Your support worker shoutd complete this port. If your support worker is supplied by on ogency,
the ogency con comptete this port.

I certiff thot the person nomed in Port 1 of this form hos

received the number of hours support shown in Port 2'

/\
Position

Signoture

Nome

Dste

t5

t//)/.6

Compony
nome ond
business
oddress

Dn
Th e Coc,"?yg"r/t
'QruJ,(
e-h'e/' el'M)}-J.-<J
if?!f
3r%,tiinl'jt
eud.Fe,to( ,RH t1
I

Lil

>{-

If you signed this os o representotlve of the ogency thot supplied the support worker,
pleose ottoch copies of the support worker's timesheets'

I clqim reimbursement of the portion of my costs ogreed with

Access to Work for the support shown in Port 2 of this form.

I wont the poyment to be mode to

I understond thot if I knowlngly give informotion thot is incorrect or

incomplete I moy be lioble to prosecution or other oction. Cloims moy be
subject to volidotion ond informotion moy be checked with other sources
including employers, s uppliers ond providers'
I hove reod the Access to Work'Informotion for Customers'ond ogree
to its terms.
No port of this cloim hos been included in ony previous cloirn.

r
o

I understond thot Access to Work will 4ot occept cloims for

reimbursement thot ore mode more thon six months ofter costs were
incurred.

Signoture

Nome

Dste

When you hove

filled in this
form send it to

DP222JP_l

22 01

1_004-001