STANDING ORDER FORM REVISED .pdf

STANDING ORDER FORM
FOR REGULAR DONATION
To set up a regular standing order complete this form and return to The Hub, 5-9 Hermitage Road, Solihull, B91 2LL.

Please do not send this form to your bank.
DONOR DETAILS

Title:

First Name:

Surname:

Address

Phone No:

E-mail:

I would like to make a regular payment for £________________ monthly
Please debit the above amount from my account on or around the 1st of __________ (month) __________ (year).

INSTRUCTION TO YOUR BANK OR BUILDING SOCIETY TO PAY STANDING ORDERS
Name & Address of your bank/building society

To: The Manager

Sort Code:

Bank

Postcode:
Name(s) of account holder(s):

Account No:

SIGNATURE:
DATE:

And thereafter the same sum in instalments to bank account
22295628 sort code 40 – 42 – 12 in the name of Solihull Health & Education Partnership
REFERENCE:

In order to Gift Aid your donation you must tick this box:
I want to Gift Aid my donation of £______________ and any donations I make in the future or have made in the past 4 years
to Solihull Health & Education Partnership. I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital
Gains Tax in the current tax year than the amount of Gift Aid claimed on all my donations it is my responsibility to pay any
difference.
Please notify the charity if you want to: (1) cancel this declaration, (2) change your name or home address (3) no longer pay
sufficient tax on your income and/or capital gains. If you pay Income Tax at the higher or additional rate and want to
receive the additional tax relief due to you, you must include all your Gift Aid donations on your Self-Assessment tax return
or ask HM Revenue and Customs to adjust your tax code.

Solihull Hub working with the Solihull Health & Education Partnership. Registered as a charity at the Charity Commission with Registration Number 1154494