Date: ......./......./.......

Title ..... Forename(s) ................................ Surname .................................................

Home Address ...........................................................................................................

...............................................................................................................

........................................................... Post Code .................................

£ .................... which I made on ......./......./....... as a Gift Aid donation.

Notes: 

• You must pay an amount of Income tax and/or Capital Gains tax at least equal to the tax the charity reclaims on your donations in the tax year.

• You can cancel this declaration at any time by notifying the charity.

• If you pay tax at the higher rate you can claim further tax relief in your Self Assessment Tax Return.