SAE Claim Form
SAE Claim Form
SAE Claim Form
DP224JP 1 06/2021
Account details for payment
Postcode
17 Provide payee’s email address if you want your remittance slip emailed
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Claim details
Please give a brief description of:
• equipment bought and the date delivered, or
• changes made to your premises or equipment and the date they were completed.
Please attach original receipts or invoices. If you do not have the originals, please attach
certified copies.
Receipts must show as a minimum:
• the amount paid:
• the person or company who supplied the equipment
• the date the equipment was bought
• a description of the equipment bought.
Description Date
DD/MM/YYYY
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Customer declaration
19 I have purchased the equipment or I understand if I give wrong or incomplete
adaptations in the Claim details section information, or I do not report changes as
at a total cost of they happen, I may:
• be prosecuted
• need to pay a financial penalty
• have my Access to Work reduced
I confirm: or stopped
• by submitting this claim I agree that the • be paid too much Access to Work and
information I have given is complete have to pay the money back.
and correct
• this is the only claim I have made for
Important – if this is your first claim, or
these costs.
payment details have changed since
I understand: your last claim, please ask for form
• if I spend my award on items not DP228JP - New or amended details.
agreed by Access to Work, DWP may
Please sign to confirm: I have read and
not reimburse me
accept the terms and conditions in my
• that Access to Work may not accept
Award Letter (ATW01CL). I confirm that
claims for reimbursement, if the claim
this declaration is correct.
is made more than 9 months after the
costs were incurred Signature
• you may check and validate my claim
with other sources. These may include
employers, suppliers and providers.
I understand and agree that DWP may
recover any money wrongly paid to me
because I did not: Name
• provide correct or complete information
or
• accurately report a change in my
circumstances. Date
DD/MM/YYYY
What to do next
When you have filled in this form send it to:
Access to Work Service Centre
Harrow Jobcentre
Mail Handling Site A
Wolverhampton
WV98 1JE
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How DWP collects and uses information
When we collect information about you we may use it for any of our purposes.
These include:
• social security benefits and allowances
• child maintenance
• employment and training
• investigating and prosecuting tax credits offences
• private pensions policy and
• retirement planning.
We may get information about you from other parties for any of our purposes as
the law allows to check the information you provide and improve our services.
We may give information about you to other organisations as the law allows, for
example to protect against crime.
To find out more about our purposes, how we use personal information for those
purposes and your information rights, including how to request a copy of your
information, please visit
www.gov.uk/dwp/personal-information-charter
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