Salary Sacrifice Payroll Information Form


Driver Details
Organisation Name: County Durham and Darlington NHS Foundation Trust
Driver Name: Mr Phil Test
Payroll No: 12345678
Driver Ref: 135816
Chosen Vehicle: FORD-MUSTANG MACH-E ESTATE - 198kW Select 72kWh RWD 5dr Auto [Tech+]
Quote Date: 19/05/2026
Please amend and confirm as necessary
Tick To Confirm
Gross Salary:
Pay Band:
Pay Point:
Tax Code:
Permanent member of staff?
How many hours per week is the Gross Salary based on?
Member of company pension scheme?
Do they have any other salary sacrifice?
If yes, what is the monthly sacrifice:
Is the employee on maternity leave?  * 
Is the employee on long term sick leave?  * 
Annual Gross Sacrifice for this car: £9483.67
Drivers Hourly Rate After Sacrifice: £14.6319
Notes: