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NHS Business Services Authority

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NDR SFE Applications
Application 3
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Edit Application 3

Edit the details of this Non-Domestic Rates Statement of Financial Entitlements application.

Provider Information

Provider name

Contract number

Provider address

Email address of Provider

Other addresses associated with this contract

Payment Responsibility

Are you solely responsible for payment of this demand?

Yes

I confirm there is no reimbursement for business rates included within the contract payment.

To enable the NHS to prevent and detect fraud and incorrectness, I consent to the disclosure of relevant information to and by the NHS Business Services Authority, NHS England, Department of Work & Pensions, HM Revenue & Customs and local authorities.

Financial Details

NHS % (proportion of gross income from NHS treatments at this property)

Value of council demand

How is the bill paid?

Monthly instalments

One lump sum

1st Half year

2nd Half year

First day of reimbursement period

Total reimbursement requested

SBRR Information

Small Business Rate Relief (SBRR)

SBRR has been claimed for this property

SBRR has not been claimed for this property

Supporting Information

NHS % (previous financial year with evidence)

Date

Signature of Provider

If signing on behalf of a corporate body please print name

! Warning Changes to this application will be logged for audit purposes.

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