<p> APPLICATION FORM Childcare Vouchers Salary Sacrifice Scheme Amendment to Contract of Employment Agreement.</p><p>Please provide ALL the information requested on this form Name Home Address</p><p>Job Title Department Payroll Assignment Number Email Address Contact Telephone Number/s Name of Childcare Provider (if known) Childcare Provider’s OFSTED Registration Number</p><p>Select your childcare voucher value based on the current rate of income tax you are paying. The Finance Office will monitor your financial position throughout your period of membership, and will make the appropriate changes to the voucher value if your tax position changes during this time. Basic Rate taxpayer: Monthly childcare voucher amount £ (to a maximum of £243) Higher Rate taxpayer (if joining on or after April 6th 2011): Monthly childcare voucher amount £ (to a maximum of £124) Additional Rate taxpayer (if joining on or after April 6th 2011): Monthly childcare voucher amount £ (to a maximum of £97)</p><p>By signing this form you are agreeing to join King’s College Hospital NHS Foundation Trust Childcare Vouchers Salary Sacrifice scheme and, in so doing, understand that this document constitutes a contractual change to your terms and conditions of employment. Instead of your original salary, you will receive an Adjusted Monthly Salary and a separate value of childcare voucher, as requested above. Please sign, date and return your application to Lenford Mendes, Payroll Services, Unit 3, King’s Business Park, King’s College Hospital, Denmark Hill, London SE5 9RS, by the last Friday of the month for action by next pay period. E.g., last Friday in March 2011 for April 2011 salary.</p><p>Pregnant employees please take special note: for reasons of eligibility and Payroll administration your application to join the scheme should reach Payroll 28 weeks before your Expected Date of Delivery (EDD). Applications (or amendment / termination requests) received later than this period cannot be guaranteed action in time to meet the qualifying criteria as set out in detail in the salary sacrifice scheme factsheet – you cannot, for example, join the salary sacrifice scheme or amend your agreement if you are less than 23 weeks away from your Expected Date of Delivery. If applicable please provide your Expected Date of Delivery, approximate if necessary: ______</p><p>I have read and understand King’s College Hospital NHS Trust’s Salary Sacrifice Scheme information as well as the Childcare Vouchers Employee Fact Sheet and agree to abide by the conditions set out in those documents.</p><p>I further testify that I am: 1. The parent or legal guardian of the child/children in respect of whom the Childcare Vouchers will be used to pay for registered or approved childcare provision as defined by HM Customs & Revenue rules; 2. Responsible for selecting the individual or institution that will provide such provision. 3. Aware that when I opt out of the scheme I will need to give Payroll one month’s notice and complete a Notification to Terminate Childcare Vouchers order form.</p><p>I wish this application to be actioned from the following pay date (mm/yy) ….……...... </p><p>Signed: …………………………………………………………………………………. Date ……………………………...</p>