HTML Preview Printable Childcare Voucher page number 1.
Salary Sacrifice Agreement
You, the Employee should complete this form and sign the declaration if you wish to enter into a Salary Sacrifice Agreement with
your Employer. See overleaf for Terms & Conditions.
SECTION 1: EMPLOYEE INFORMATION
Title: First Name: Surname:
Job Title: Department:
National Insurance Number: Payroll Number:
Home Address:
Post Code:
Home Telephone Number: Work Telephone Number:
E-mail Address: Date of Birth:
SECTION 2: CHILD / CHILDREN’S INFORMATION
The children for whom the Employee is responsible and for whom the Employee will pay for childcare
Name of Child Date of Birth Relationship to Employee Registered Disabled? Y/N
1
2
3
SECTION 3: CARER INFORMATION
You, the Employee, only need to provide details of one Carer at this stage, You can also use your Childcare Vouchers to pay other
registered or approved Carers who are affiliated with Edenred UK.
Name of Carer
Registration or Approval Body (e.g. Ofsted)
Registration or Approval Number :
Please contact your Carer as soon as possible to find out if they are affiliated with Edenred. If they are, simply ask them for their
Edenred Account Number which you will need in order to transfer electronic vouchers to them online (this account number begins
with a “P” and is issued to Carers when they affiliate with Edenred.)
If you are to receive paper Childcare Vouchers, you can hand them to your Carer once they are affiliated
If your Carer is not already affiliated with Edenred, they should complete a Carer application form online by visiting
www.childcarevouchers.co.uk and clicking on ACCEPT VOUCHERS in the Childcare Providers area.
You can download a printable Carer application form from the same website if your Carer does not have internet access.
SECTION 4: VOUCHER INFORMATION
Your employer should have completed a basic earnings assessment which will tell you the upper limit of the range available to you. If you
are not aware of this please contact your employer to request a basic earnings assessment prior to submitting this agreement.
Weekly paid
4-Weekly paid
Monthly paid
Basic rate category
(Maximum £55)
(Maximum £220)
(Maximum £243)
Higher rate
category
(Maximum £28)
(Maximum £112)
(Maximum £124)
Additional Rate
category
(Maximum £25)
(Maximum £100)
(Maximum £110)
SECTION 5 : WHAT HAPPENS NEXT
When you have completed this form, please check with your Employer when you should expect to receive your first vouchers
Your Employer will contact Edenred to order the vouchers on you behalf, to the value you have chosen on this form.
Shortly before you receive your first vouchers, you will receive a Parent Welcome Pack from Edenred explaining how to use your
electronic or paper Childcare Vouchers.
DECLARATION:
As the Employee, I have read and agree to the variation in my contract of employment with the Employer, as defined in the Terms &
Conditions of this Salary Sacrifice Agreement (see over). I hereby authorise the Employer to reduce my salary accordingly.
Signature (employee) …………………………………………………………………… Date: …………………………………………………………