Claim Form

Personal information

Initial(s)

Family name

Date of birth

Street

House number

Postcode

City

Country

Phone number

Email address

Student UvA

Yes No

Bank details

Bank account type

IBAN (NL) IBAN (non-NL) non-IBAN

Account holder

Cost Centre or WBS-element

Name Contact

Phone Contact

Claim from

Claim to

Reason for claim

Select a cost type

Please select at least one cost expense.

Total amount

€

Attachments (.jpg, .jpeg, .png, .pdf)

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Confirmation

Document date

I confirm that the information is accurate and true.

Your data will only be used to process your claim or when we need to contact you for more information.

Please check all form requirements