Forms 5223C and 5223D
| Published date | 21 March 2018 |
| Subject Matter | Jury service forms |
Certicate of Loss of Earnings or Benet
This form is only to be completed if the employer is NOT paying
the employee their normal salary while on jury service.
To the Employer or Benet Oce
Jury Service normally lasts for 10 days and you may wish to continue paying your employee whilst they are
undertaking their public duty. If you do not pay your employee whilst they attend Jury Service, your employee may
claim an allowance towards their loss of earnings.
Please complete all parts of the certicate and return it to your employee, who is required to take it to the court on
their rst day of jury service.
Knowingly providing false information on this form may lead to prosecution.
Name of Crown Court Juror’s no.
Details about your employee
Full name of employee
Occupation
Net Daily Earnings/Loss of benet per day
£
This is the amount remaining after you have subtracted
income tax and National Insurance contributions.
Please indicate the day and the hours worked by your
employee during the week:
Week 1 Week 2
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday COURT CLOSED
Sunday
If shift work, please give rotas for the relevant period.
If your employee is not required to attend court will
they be able to return to work?
For a full day Yes No
For a half day Yes No
Before the end of the 2 weeks Yes No
Declaration
I certify that the information supplied is correct and
I understand that I may be prosecuted if I have given
any information, which I know to be false or do not
believe to be true.
Signed
Print your name
Date
Your position in the business or local benet oce
Phone no.
Please put the business, or local benet oce stamp
in this space OR attach a compliment slip
Name and address of the business or local benet oce
Certicate of Loss of Earnings or Benet (08.16)
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