Youth Contract

Wage Incentive – Bank Account Details
Please use BLACK ink and capitals throughout, and complete all boxes that apply.

Part 1: Employer Details 

Employer Name

Employer Address

Telephone Number

Contact Name

Part 2: Employer Bank Details 

Bank/Building							      Sort Code 
Society Name
							     
Branch Name

Branch Address

Bank Account Name

Bank Account/Building
Society Roll Number

Remittance Advice
Address (if different to
Part 1 as above)

Part 3: Authorised Signatories

The names and specimen signatures of people authorised to sign Wage incentive claim forms on behalf of the employer are shown below. These signatures are binding on this organisation in respect of claims submitted for payment.

Name							Name

Position						Position

Signature						Signature

Date							Date

Part 4: Employer Declaration

•	I certify that the information given on this from is correct
•	I agree that following discussions, any overpayments can be automatically recovered from future payments

Signature						Name

Date

Data Protection Act 1998: The information on this form will be recorded on a computer system. The information provided will be used for paying your fees and will not be passed to anyone outside of DWP or Purchase to Pay.

Return this form to your payment processing centre at the following address:
Provider Payment Validation Team, 
Room 216, 2nd Floor,
Brunswick House Birkenhead Jobcentre Plus, 
Brunswick House Jobcentre Plus, 
29 Price Street, 
Birkenhead, CH41 6JN.

Signature

Name

Date

Part 5: For DWP Use Only (for completion by DWP)

Tick one Box only

            Set up a new supplier/site record for the organisation named overleaf (RM7 Action)

Amend the existing record for the organisation named overleaf – Now complete the   box below
Use the “supplier” window on RM to obtain the following details:

Supplier name 					Site name

Signature						Name

Date					      Grade 		Tel No