Form 43.9

Form of Statement of Valuation of Claim

Head of Claim
	Components	Valuation	
Solatium	Past
Future
	£x
£x	
Interest on past solatium
	Percentage applied to past solatium (State percentage rate)
	£x	
Past wage loss	Date from which wage loss claimed
(……………….)
Date to which wage loss claimed
(……………….)
Rate of net wage loss (per week, per month or per annum)
	£x	
Interest on past wage loss	Percentage applied to past wage loss (State percentage rate)
	£x	
Future wage loss	Multiplier
(……………….)
Multiplicand (showing how calculated)
Discount factor applied (if appropriate)
Or specify any other method of calculation
	£x	
Past services	Date from which services claimed
(……………….)
Date to which services claimed
(……………….)
Nature of services
(……………….)
Person by whom services provided
(……………….)
Hours per week services provided
(……………….)
Net hourly rate claimed
(……………….)
Total amount claimed
(……………….)
Interest

£x	
Future loss of capacity to provide personal services
	Multiplier
(……………….)
Multiplicand (showing how calculated)

£x	
Needs and other expenses	One of Multiplier
(……………….)
Multiplicand
Interest
	£x

£x	
Any other heads as appropriate (specify)