Claim Form for Additional Financial Expenses Incurred Because of Phoenix Pay System Errors
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| Title | Claim Form for Additional Financial Expenses Incurred Because of Phoenix Pay System Errors |
|---|---|
| Number | (TBS/SCT 330-0321) |
| Category | Pay, pension and benefits |
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How to Complete This Claim Form
Please note that an asterisk (*) denotes a mandatory field in the claim form.
Section 1: Claimant information
Enter the required information in each field. Leave the "Claim No." box blank, as it is for administrative use only.
Section 2: Statement of Facts
Section 2 has three parts.
First, describe the pay problem you experienced and attach supporting documents.
In the first part of this section, you are asked to describe the pay problem you experienced. Please provide a brief but clear outline of what happened and include the dates involved.
Attach documents such as pay stubs, bank statements or screen captures of Phoenix payments that show evidence of your pay problem.
Two examples of statements of facts about pay problems
- On March 9, March 23 and April 6, 2016, I did not receive my biweekly pay deposits in my bank account. Each pay deposit should have been for $X,XXX, for a total of $X,XXX. I received an emergency salary advance of $X,XXX on April 20. My regular pay was reinstated on May 4.
- I started working for National Defence on May 16, 2016, but my first pay deposit was not made until July 27, 2016. From May 16 to July 27, my net biweekly pay should have been $X,XXX, for a total of $X,XXX.
Second, describe the out-of-pocket expenses you incurred because of your pay problem. Also attach supporting documents.
In the second part of Section 2, you are asked to provide a statement of facts that explains the amount of out-of-pocket expenses you are claiming.
For each expense, list your supporting document and attach a copy. Here are some examples of the types of documents you might be using:
- A household utility bill showing the penalty for late payment and resulting interest charges;
- A bank statement showing additional interest charges;
- A bank statement showing NSF charges.
Note: In your supporting documents, please cross out any information that concerns transactions that are not related to your claim.
Two examples of statements of facts about out-of-pocket expenses
- At the end of March 2016 and at the end of April 2016, I did not have enough money in my bank account to cover my monthly pre-authorized payment for my car loan. This resulted in:
- A penalty fee of $XX for each missed payment;
- An NSF bank charge of $XX for each missed payment.
Supporting evidence provided:
- A copy of my bank statement showing the penalty fees incurred because of the missed car payments;
- A copy of my bank statement showing the NSF bank charges incurred because of the missed car payments.
- During this time without pay, I had to get a cash advance on my credit card in order to pay for groceries during May and June. This resulted in:
- Interest charges of $XX on my credit card.
Supporting evidence provided:
- A copy of my credit card statements showing the cash advances on my credit card and interest charges for May and June 2016.
Third, use the table in Section 2 to list each out-of-pocket expense you incurred because of your pay problem.
In the table in Section 2, provide the following details for each out-of-pocket expense you incurred:
- Date
- Amount
- Type of expense
- Type of document you are providing that supports your claim for the expense
Example of an entry in the table in Section 2:
| Date the expense was incurred (yyyy-mm-dd) |
Amount of the expense claimed | Type of expense (NSF or penalty charge, interest, other) |
Type of document attached that supports your claimed expense (bank statement, loan agreement, line of credit statement, household utility invoice, credit card statement, invoice from financial service provider, other) |
|
|---|---|---|---|---|
| 1 | 2016-08-23 | $45.00 | NSF charge | Bank statement |
Also be sure to provide the total amount you are claiming in the field provided.
Section 3: Certification and Consent
In Section 3, please indicate whether you or another public servant has filed a grievance regarding the expenses listed in this claim. If so, please provide the grievance reference number.
Certify your claim by signing it. By signing, you certify that neither you nor another person who is also a public servant has made a previous claim for the items listed in this claim form, and that the statements made in this claim are true and complete.
Please also provide consent for your departmental claims officer to disclose your personal information to the Treasury Board of Canada Secretariat's Claims Office. For the purposes of processing this claim, your information may be shared with the Canada Revenue Agency, Employment and Social Development Canada, and Public Services and Procurement Canada.
How you can help us process your claim quickly
To avoid delays in processing your claim, please remember to:
- Complete all required fields in your claim form;
- Include all required supporting documentation;
- Date and sign your claim.
- Submit your claim package to your claims officer. Your organization will communicate to you how to send your completed claim.
If you need further guidance on how to complete and submit your claim, please contact your departmental claims officer or refer to the frequently asked questions on the Treasury Board of Canada Secretariat website.
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