From (Please Complete Your Contact Details)

DONATION FORM

From (please complete your contact details)

Name:…………………………………………………….

Address:…………………………………......

…………………………………......

Tel No:…………………………………......

Email:…………………………………......

I wish to make a donation to Budleigh Salterton and District Hospiscare of £ ………

as a *single payment/monthly payment/annual payment/other* – please specify). (* delete as applicable).

To make a single payment, please enclose this form with your cheque (made payable to Budleigh Salterton and District Hospiscare).

Should you wish to make a regular donation, please complete the Standing Order below.

We are most grateful for any support you are able to give. If you wish to let us know the reason for your donation, please include this here.

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

STANDING ORDER

Bank name:……………………………………......

Bank address:……………………………………......

……………………………………......

Please pay on (insert date of first payment) …………………………. to HSBC, 9 Chapel Street, Exmouth EX8 1HR for the credit of Budleigh Salterton and District Hospiscare, Account No 61504312, Sort Code 40 20 32the sum of (words) …………………………………..….. pounds (£………..)

and continue to pay the same amount monthly/annually* until further notice.

(* delete as applicable)

Signature:…………………………………......

Bank Sort Code:……………………………………………..

Bank Account No:…………………………......

Bank Account Name:………………………………………….....

Please return this form to Budleigh Salterton and District Hospiscare, The Medical Centre, 1 The Lawn, Budleigh Salterton, EX9 6LS.

Registered Charity No 1162329

GIFT AID DECLARATION

If you wish Budleigh Salterton & District Hospiscare to have the benefit of tax advantages now available, please complete the Gift Aid section below. This will enable us to reclaim a refund of tax of 25 pence for every £1 donated. The only stipulation is that the person who gives must pay an amount of tax which is more than the Charity will claim back. If this no longer applies in the future, it will be necessary to notify us.

I am a UK taxpayer and I want Budleigh Salterton and District Hospiscare to claim back the tax on *this donation, *all donations I have made in the last 4 years (including donations to Budleigh Salterton and District Hospiscare charity number 290076) and *all future donations (* please delete as applicable) until I notify you otherwise.

I confirm I have paid or will pay an amount of income tax and/or capital gains tax for each tax year (6 April to 5 April) that is at least equal to the amount of tax that all the charities or Community Amateur Sports Clubs (CASCs) that I donate to will reclaim on my gifts for that tax year. I understand that other taxes such as VAT and Council Tax do not qualify. I understand that Budleigh Salterton and District Hospiscare will reclaim 25p of tax on every £1 that I give.

Data Protection Statement

Supporters of Budleigh Salterton and District Hospiscare are precious and we respect your privacy. We will not sell or give your details to other organisations for marketing purposes without your express consent. We would like to keep you informed about our work and events. If you prefer not to receive this information, please tick here  or you can let us know at any time by phone, email or post. Please also let us know if you change your contact details below.

Signature:…………………………………………………………………….

Date:………………….………………………………………………..

Name:……………………………………......

Address:……………………………………......

……………………………………......

Tel No:……………………………………......

Email:……………………………………......

Please return this form to Budleigh Salterton and District Hospiscare, The Medical Centre, 1 The Lawn, Budleigh Salterton, EX9 6LS.

Registered Charity No 1162329