Dorset Health Authority

GP REGISTRAR

APPLICATION FOR ASSISTANCE WITH RELOCATION EXPENSES

APPLICANTS NAME DR ______DORSET FAMILY HEALTH SERVICES AGENCY

DECLARATIONS IN RESPECT OF RELOCATION EXPENSES

 I hereby make application for assistance with relocation expenses actually and necessarily incurred by me in connection with my new appointment and I hereby declare that the information and costs incurred and included by me in this application are correct in all details.

Signed ______Date ______

 I hereby undertake to repay a proportion of any relocation expenses received, if I leave my post within 6 months of the commencement of the contract period/ training programme. The proportion will be calculated by reference to that element of my contract of employment /training programme I have worked to the full length of my contract of employment/training programme.

Signed ______Date ______

 I certify that all of the expenses in connection with this Application claim are not recoverable in full or in part from any other source, and that no other member of my family is eligible to claim relocation expenses in respect of this relocation. I also certify that I have not received a Miscellaneous Expenses Grant in the last two years.

Signed ______Date ______APPLICATION FOR ASSISTANCE WITH RELOCATION EXPENSES

 NAME OF APPLICANT ______(BLOCK LETTERS)

 NEW APPOINTMENT

Post ______

Grade & Salary ______

Wholetime/Part-time ______

Date of Commencement ______

 PREVIOUS APPOINTMENT

Authority/Trust ______

Post ______

Grade & Salary ______

Wholetime/Part-time ______

Permanent/Locum* ______

Termination date ______

(* If locum appointment (s) please give details back to previous permanent post.)

 PRESENT ADDRESS ______

______

 PREVIOUS ADDRESS ______

______

 DATE OF REMOVAL ______DETAILS OF ACTUAL EXPENSES INCURRED

 Removal of Household furniture and effects (attach 3 tenders)

Lowest tender £______

Storage charge (if any) £______

Insurance: Extra cost of Insuring furniture in storage or transit. £______

TOTAL CLAIMED £______

 Legal Expenses in connection with Purchase of Property *

Solicitors Fees £______

Stamp Duty £______

Land Registration fees £______

Survey fees £______

Drains Testing £______

Private Survey Fees £______

Incidental Legal Expenses £______

Other £______

PURCHASE PRICE OF PROPERTY £______

 Legal Expenses in connection with Sale of Property *

Legal cost of sale ( including expenses in redemption of mortgage) £______

House Agents or Auctioneers fees £______

Advertising costs £______

Incidental Costs £______

SELLING PRICE OF PROPERTY £______DETAILS OF ACTUAL EXPENSES INCURRED

 Cost of Tenancy Agreement – Rented accomodation *

Cost of Agreement (tenant’s share) £______

House Agents fees (tenant’s share) £______

Cost of Drains Testing £______

 Travelling and Subsistance Expenses *

Preliminary Visit

Date ______

Subsistance Allowance £______

Mileage claimed ______

Journey from Old to New Home

Date ______

Subsistance Allowance £______

Mileage claimed ______

 Miscellaneous Expenses Grant **

Salary of old appointment £______

Married YES/NO

Number of children ______

Ages at time of appointment ______

( A child for this purpose is a member of the household aged 4 years or over and receiving full-time education, or under 17 years of age and serving a full-time apprenticeship who has to go to another school or place of apprenticeship because of the move.)

* Please attach receipted accounts ** Please attach a statement of the miscellaneous expenses for which this miscellaneous Expenses grant is being claimed. APPLICATION FOR EXCESS RENT ALLOWANCE

 NAME

 GRADE

 STATUS

 DATE OF NEW APPOINTMENT

 LONDON WEIGHTING

 PERCENTAGE OF REMOVAL EXPENSES PAYABLE

 ACCOMODATION IN NEW AREA:

Date of occupation ______

Furnished or unfurnished ______

Buying Price ______

Annual ground rent and/or feu duty ______

Annual title payment ______

Annual Insurance of property ______

 ACCOMODATION IN OLD AREA:

Owner occupier/Tenant ______

Furnished or Unfurnished ______

Selling Price ______

Annual ground rent and/or feu duty ______

Annual title payment ______

Annual Insurance of property ______