Salary Support Scheme

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Employer Details

Employer Name

Employers’ Tax Reference

Claim Period

Business Sector

Description of Business Activity

2000 characters left

Contact Name

Telephone

Companies Only

Company Registration (optional)

Beneficial Ownership

Probity Requirements

I hereby confirm all of the following statutory probity requirements:

no person involved in controlling or managing the business is disqualified from holding an appointment as a director or a company secretary anywhere in the world at the time of the application;
no person involved in controlling the business is the subject of outstanding executions anywhere in the world at the time of application;
no person involved in controlling the business is insolvent at the time of application; and
the business is not insolvent at the time of application.

Yes No

Arrears

Please declare whether the business has any arrears in relation to:

Income Tax;
National Insurance contributions;
VAT;
Any other taxes or duties payable

Yes No

If yes please state which tax/obligation the arrears relate to and the amount.

3000 characters left

Registered Address

Address search

Address Line 1

Address Line 2 (optional)

Address Line 3 (optional)

Town

Post Code

Country

Banking Details

Bank Account Name Reference – (only used for reference purposes i.e. this does not need to exactly match the name on the account)

Account Number

Account Number Confirmation

Sort Code

Sort Code Confirmation

File Attachment

For guidance on how to complete the form and populate the spreadsheet please see the guidance notes available here.

Please select a claim period in order to make the correct template available for downloading.

Please attach the completed employees template(s)

Claimed Amount

I am hereby submitting this claim under the COVID-19 Salary Support Scheme for the above period and for the employees detailed in the attached spreadsheet for the total amount of:

Additional Comments

Any overall additional comments that you may wish to add in relation to your application:

3000 characters left

Qualifying Business Declaration

I declare that:

I am a Qualifying Business under the terms of the Scheme and the issued guidance. In particular I specifically hereby confirm that this business meets all of the following statutory requirements:

it has 1 or more employees;
is not in an excluded sector as defined at Section 3 of the scheme and in the guidance;
has its place of business in the Isle of Man;
has been consistently meeting in full its financial obligations to its employees up to 28 February 2020 or where established after 28 February 2020 from the date the business was established;
has not laid off any employee for whom financial assistance has been sought;
has remunerated every employee for whom financial assistance has been sought at least to the level of the statutory minimum wage;
has been in operations continuously since at least the 28 February 2020 or where established after 28 February 2020 from the date the business was established up to and including the day before the beginning of the first 4 week claim;
intends to continue operating during the current statement of emergency in effect due to the COVID-19 pandemic and for the foreseeable future; and
has been adversely affected through loss of business by the COVID-19 outbreak.

Yes No

If you do not consider that you are a qualifying business under the scheme as you cannot meet the conditions stated above please state what conditions you cannot meet and why you consider you are still eligible for the scheme. If you have received a specific approval for inclusion from the Chief Financial Officer please include the CFO approval reference here.

2000 characters left

Authorised Signatory

Name of Person Submitting this claim on behalf of the business

Position Held in Business

I hereby declare that:

I have read, understood and complied with the terms of the Scheme and accompanying Guidance
I am authorised to submit this application on behalf of the business
I have made due enquiry in my own right and on behalf of the business whose employees are the subject of this application
Those enquiries extend to others with control or management of the business and the employees concerned
The information I have given on this form is correct and complete in relation to the period it covers as to:
1. the particulars of the business
2. the qualification of the business under the Scheme
3. the employees particulars
4. the amounts claimed
I understand that the information I have given on this form may be checked with other sources.

I understand that if I give information that is incorrect or incomplete I and/or the business may

be prosecuted
be liable to repay monies paid over

I confirm the above to be true and correct