Gift Aid Declaration Form 1

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0 height="100%"><tr> <td valign="top" width=0 style="border-right: 1px solid #CCCCCC;" BGCOLOR="#FFFFFF" TEXT="#080000"> <bR> </td> <td valign="top" BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <FONT SIZE="3" COLOR="#BF0000" FACE="Arial" ><B>To print this form scroll to bottom of page</B></FONT><B>          Go back</B><B> to: </B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="id80_gift_aid1.htm" TARGET="_top" TITLE="Donate Money"><B>Donate Money</B></A></FONT></div> <div> <TABLE BORDER="1" CELLPADDING="11" CELLSPACING="0" WIDTH="590" HEIGHT="1%" BORDERCOLORLIGHT="#111111" BORDERCOLORDARK="#111111" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 753 WIDTH="564"><div> <B>GIFT AID DECLARATION - </B><FONT SIZE="2" COLOR="#FF0000" FACE="Arial" ><B>UK tax payers only</B></FONT></div> <bR> <div> <B>Name of Charity</B><B>:</B><B>  </B>BANSANG HOSPITAL APPEAL - Registered Charity No 1064469</div> <div> <B>Address</B><B>:</B><B>     </B>4 The Leys, Orlingbury, Kettering, Northants.  NN14 1JE</div> <bR> <div> <B>Details of Donor</B></div> <div> Title  Mr, Mrs  _______  </div> <bR> <div> Forename(s)  ___________________________  Surname  _________________________</div> <bR> <div>  Address         _____________________________________________________________</div> <bR> <div>                         _____________________________________________________________</div> <bR> <div>                         ________________________________    Post Code   _________________</div> <bR> <div> <B>Declaration.</B></div> <div> I require the above named charity to treat the following donation as a Gift Aid donation. </div> <div> <B>>  </B>The enclosed donation of  £  ________________</div> <bR> <div> <B>>  </B>The donation (s) of  £  ________________     which I made on          /           /</div> <bR> <div> <B> >  </B>All donations I make from the date of this declaration until I notify you otherwise</div> <bR> <div> <B>></B><FONT SIZE="2" COLOR="#FF0000" FACE="Arial" ><B>  </B></FONT><FONT SIZE="2" COLOR="#000000" FACE="Arial" >All donations which I have made since 6 April 2000, and all further donations that I </FONT></div> <div>     make from the date of this declaration until I notify you otherwise.</div> <bR> <DIV ALIGN="LEFT"></DIV> <div> <B>Delete as appropriate whichever of the above do not apply to your donation.</B></div> <bR> <div> I confirm that I pay income tax and / or capital gains tax, in the current tax year, at least equal to the tax that the charity will reclaim on my donation(s) ~ (currently 28p for each £1.00).</div> <bR> <bR> <div> <B>Signed      _________________________________   Date  ____________________                            </B></div> <bR> <div> <B>Notes </B></div> <div> <B>1</B>. This declaration may be cancelled at any time by notifying the charity in writing.</div> <div> <B>2</B>. If in the future your circumstances change and you no longer pay income tax and / or capital gains tax equal to the tax that the charity reclaims - you must cancel this declaration.</div> <div> <B>3</B>. If you pay tax at the higher rate you can claim further tax relief in your self assessment tax return.</div> <div> <B>4</B>. If you are unsure whether your donation will qualify for Gift Aid tax relief please ask your local tax office for leaflet IR65. </div> <div> <B>5</B>. Please notify the Bansang Hospital Appeal if you change your address.</div> </tD> </tR> </TABLE></div> <div>  <form><input name="Print" onClick="window.print();return false" type="button" value="Print this form"></form>  </div> <div> <B>Go back to: </B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="id80_gift_aid1.htm" TARGET="_top" TITLE="Donate Money"><B>Donate Money</B></A></FONT></div> <bR> <bR> </td> <td valign="top" width=0 style=" border-left: 1px solid #CCCCCC;" BGCOLOR="#FFFFFF" TEXT="#080000"> <bR> </td> </tr></table></body>