Company Name:*


Tax Year:*

Senders Email:*

Who is your accountant?

Benefits Received

During the tax year period, as selected above, please confirm if you have received any of the following benefits from your Limited Company

1. Company Car


Make & Model:

Date first registered:

Is the Vehicle a van?

Engine size(cc):

Date car available from:

Date car available until:

Carbon dioxide (CO2) emissions (g/km):

Petrol/Diesel/Other (Specify):

List price when new:

price of optional extras:

was fuel provided for private use?
Capital Contribution made:

2. Private Health/Medical Insurance


Annual cost to the Company of any Private Health Insurance:

3. Life Insurance (excluding Relevant Life Policies)


Annual cost to the Company of any Life Insurance (excluding Relevant Life Policies:

4. Income Protection (where the company is not the beneficiary)


Annual cost to the Company of any Income Protection Insurance

5. Company Assets

Complete details of any company asset that has been made available for private use (for example Company motorbike.) Please do not declare assets that are substantially for business use, where private use is not significant.


Description of Assets:
Market Value when asset first made available for private use:
Purchase Date:

7. Other non-business expenses

Details and totals of any other expenses reimbursed to you by your Company. that were not wholly, exclusively and necessarily for business.


Expense Description

8. Any Other Information

Please provide any other details that you may thin relevant in completing your P11D/S336 Claim.


9. Declaration

Are there other employees/directors in the company?:


I will be sending in more returns; number in total:

I Confirm that the above questionnaire is complete to the best of my knowledge.*

When you submit this form a copy will be sent to the relevant point of contact and a confirmation email will also be sent to you to acknowledge receipt.