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Declaration from a party/witness who is self employed and claiming loss of earnings

Document Cited in Related
Vincent
Published date21 March 2018
Subject MatterEmployment tribunal forms and guidance
Declaration from a party/witness who is
self employed and claiming loss of earnings
Note: A claim can only be made where attendance relates to an
employment tribunal claim made on, or before, 6 April 2012.
Please provide the following statement on your headed paper or attached to your business card:
I conrm that as a result of attending the tribunal on
I lost income to the amount of
I could not carry out the work specied below which I could not advance or defer.
(If possible, to support your claim, please provide a recent copy invoice).
I was (the self employment undertaken)
for (name and address of individual, organisation or company to whom you were supplying a service)
Signed
Date
Print name
Please sign and date this declaration and attach it to your form Party/witness - claim for attending an
Employment Tribunal (TSF4).
General Data Protection Regulations
The Ministry of Justice and HM Courts and Tribunals Service processes personal information about you in the
context of tribunal proceedings.
For details of the standards we follow when processing your data, please visit the following address https://
www.gov.uk/government/organisations/hm-courts-and-tribunals-service/about/personal-information-charter.
To receive a paper copy of this privacy notice, please call 0300 123 1024 Textphone 18001 0300 123 1024. If
calling from Scotland, please call 0300 790 6234 Textphone 18001 0300 790 6234.
/ /
£
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T439 Declaration from a party/witness who is self employed and claiming loss of earnings (07.18) © Crown copyright 2018

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