Work at Home Claim Form

Your Name
Email
example@example.com
Start of Tax Year

Day Month Year
Date
End of Tax Year

Day Month Year
Date
Number of days of Annual leave or Sick leave taken
Work at Home due to Coronavirus
Start Date

Day Month Year
Date
End Date

Day Month Year
Date

Total days worked at home due to Coronavirus

	Number of days worked
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Average number of hours worked per day
Regular Work at Home
Start Date

Day Month Year
Date
End Date

Day Month Year
Date

Total days worked as regular work at home

	Number of days worked
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Average number of hours worked per day
Any other information or comments
Should be Empty:

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