Please indicate below the hours you would have worked (if part time) on the relevant strike day
                            
                        
                     
                    
                        
                            
                                Strike Day
                            
                            
                                On Strike
                            
                            
                                Number of Hours (only required if part time)
                            
                         
                     
                    
                    
                    
                    
                    
                    
                     
                    
                    
                     
                    
                    
                    
                    
                    
                    
                    
                    
                    
                    
                    I hereby state that I was on strike on the date(s) shown and that my employer has confirmed deduction of pay in respect of these days.
                    
                    
                    
                 
                 
                 
                 
                
                Payment will be calculated as 75% of gross pay deducted, multiplied by the estimated net pay percentages as per the table below.
                All payments will be credited to the bank details held against your membership record.
                1. STPS
                
                    
                        | 2025/2026 Tax year. Net Pay Percentages | Up to £34,869 | £34,870 to £46,940 | £46,941 to £55,659 | £55,660 to £67,975 | £67,976 to £92,693 | £92,694 And Above | 
                    
                        | Gross pay lost | 100.0 | 100.0 | 100.0 | 100.0 | 100.0 | 100.0 | 
                    
                        | Less: Superannuation Contributions (Note 1) | 7.35 | 8.88 | 9.9 | 10.61 | 11.73 | 12.14 | 
                    
                        |  | 92.65 | 91.12 | 90.1 | 89.39 | 88.27 | 87.86 | 
                    
                        | Less: Income Tax (- tax relief) | 10.1 | 12.2 | 14.9 | 18.1 | 22.2 | 24.2 | 
                    
                        |  | 82.55 | 78.92 | 75.2 | 71.29 | 66.07 | 63.66 | 
                    
                        | Less: National Insurance (Note 2) | 4.6 | 5.5 | 6.0 | 5.3 | 4.5 | 4.2 | 
                    
                        |  | 77.95 | 73.42 | 69.2 | 65.99 | 61.57 | 59.46 | 
                    
                        | Rounded to: | 78% | 73% | 69% | 66% | 62% | 59% | 
                
                
                
                
                2. USS
                
                    
                        | 2025/2026 Tax year. Net Pay Percentages | Up to £34,869 | £34,870 to £46,940 | £46,941 to £55,659 | £55,660 to £67,975 | £67,976 to £71,484 | £71,485 and over | 
                    
                        | Gross pay lost | 100.0 | 100.0 | 100.0 | 100.0 | 100.0 | 100.0 | 
                    
                        | Less: Superannuation Contributions (Note 1) | 6.1 | 6.1 | 6.1 | 6.1 | 6.1 | 6.1 | 
                    
                        |  | 93.9 | 93.9 | 93.9 | 93.9 | 93.9 | 93.9 | 
                    
                        | Less: Income Tax (- tax relief) | 10.3 | 12.8 | 16.1 | 20.0 | 22.2 | 24.4 | 
                    
                        |  | 83.6 | 81.1 | 77.8 | 73.9 | 71.7 | 69.5 | 
                    
                        | Less: National Insurance (Note 2) | 4.6 | 5.5 | 6.0 | 5.3 | 4.9 | 4.5 | 
                    
                        |  | 79 | 75.6 | 71.8 | 68.6 | 66.8 | 65 | 
                    
                        | Rounded to: | 79% | 76% | 72% | 69% | 67% | 65% | 
                
                
                
                Notes
                (1)	As Superannuation Contributions are banded according to earnings the above columns approximate the contributions made.
                
                    (2)	Similarly National Insurance contributions vary according to earnings. For the first £242 of weekly earnings there are no National Insurance contributions paid by employees. Earnings between £242
                    and £967 are paid at 8%, and above £967 are paid at 2%.
                
                (3)	For employees not in the Superannuation scheme the reimbursement will be 82% of gross earnings.