Form 5223F
| Published date | 21 March 2018 |
| Subject Matter | Jury service forms |
Certicate of Loss of Earnings
for self-employed or company directors
Name of Crown Court Juror’s no.
If you are not required to attend court on a particular day will
you be able to return to work?
For a full day Yes No
For a half day Yes No
Declaration
I certify that I normally earn £ (gross) per day and that I have lost/will lose that amount each day.
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
Certicate of Loss of Earnings - self-employed or company director (08.17)
You should use this form if you are self-employed or a company director and need to claim for earnings you
lose while serving as a juror.
You cannot claim for a loss of earnings for work at the weekend or a bank holiday, as you will not be serving as a juror
when the courthouse is closed, and so will not incur a nancial loss during those days.
You must supply documents as evidence of the amount you would have earned while you served as a juror and
evidence that you are registered as self-employed or a salaried company director with HMRC. See overleaf for a
checklist to advise what documents the Court requires to consider your claim. The Court cannot pay any charges from
your accountant to provide any information. The Jury Ocer/Manager will be able to advise you if your documents
and evidence are acceptable to prove your claim.
Each claim will be assessed on a case-by-case basis. If you have any questions about claiming for nancial loss in
your circumstances, please speak to a member of sta. They can advise you what you are entitled to claim and what
evidence you need to provide to make your claim.
Your name
Your profession
On what date will you return to work?
Which days and hours do you usually work?
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Hours worked COURT CLOSED
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