Appendix 4

Sample Claim Form

 

Promoter Name:

Promoter ID No.:

 

Project Expenditure Details

Invoice No.

 

Supplier

Invoice Date

 

Total €

 

VAT €

Eligible Amount €

VAT Registered Y/N

 

VAT No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total Eligible €

 

 

Payment Calculation

 

Theme:

 

Sub-Theme:

 

 

Grant Rate:

 

Total Eligible:

 

Total Due:

(Total Eligible x Grant Rate)

 

Tax Reference Number:

 

Tax Clearance Access Number:

 

 

Date of Check:

 

Promoters Signature:                                            Date: