GIFT AID DECLARATION - UK tax payers only Name of Charity:  BANSANG HOSPITAL APPEAL - Registered Charity No 1064469 Address:     4 The Leys, Orlingbury, Kettering, Northants.  NN14 1JE Details of Donor Title  Mr, Mrs  _______   Forename(s)  ___________________________  Surname  _________________________  Address         _____________________________________________________________                         _____________________________________________________________                         ________________________________    Post Code   _________________ Declaration. I require the above named charity to treat the following donation as a Gift Aid donation. >  The enclosed donation of  £  ________________ >  The donation (s) of  £  ________________     which I made on          /           /  >  All donations I make from the date of this declaration until I notify you otherwise >  All donations which I have made since 6 April 2000, and all further donations that I     make from the date of this declaration until I notify you otherwise. Delete as appropriate whichever of the above do not apply to your donation. 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). Signed      _________________________________   Date  ____________________                             Notes 1. This declaration may be cancelled at any time by notifying the charity in writing. 2. 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. 3. If you pay tax at the higher rate you can claim further tax relief in your self assessment tax return. 4. If you are unsure whether your donation will qualify for Gift Aid tax relief please ask your local tax office for leaflet IR65. 5. Please notify the Bansang Hospital Appeal if you change your address.