Donation Record
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St Barnabas House
Chestnut Tree House
Donor Name (Mr/Mrs/Ms/Miss):
Address:
Post Code:
Telephone No:
Amount:
Cheque/Cash:
For Donations in Memory
Donation in Memory of ____________________________________________________
Please notify next of kin: Yes/No
I would like my Donation to be treated as Gift Aid
Gift Aid Declaration
Please reclaim TAX on this Donation and ALL Donations I make on or after the date of
this Declaration (please refer to notes below)
Signature:
Date:
Notes :
 You must pay an amount of Basic Rate Income Tax or Capital Gains Tax equal
to the tax we reclaim on your donations.
 Remember to notify us if your circumstances change and you cease to pay an
amount of Income Tax or Capital Gains Tax equivalent to the above amounts
 Please notify the charity if you change your name or address while the
declaration is still in force.
 You can cancel the declaration at any time by notifying the charity; the
cancellation will have effect only in relation to donations received by us on or
after the date on which the notification is received or such a later date as you
specify.
Registered as a Charity No. 256789