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Mind in Kingston - Standing Order Form

Please print out, complete and post to Mind in Kingston, Siddeley House, 50 Canbury Park Road, Kingston Upon Thames, Surrey KT2 6LX.

I would like Mind in Kingston to treat the donation amount (stated below) as a Gift Aid donation. I confirm that I am a UK tax payer and pay an amount of Income Tax or Capital Gains Tax equal to the tax Mind in Kingston reclaims on my donation.

Yes:

No:

   

Name:

Address:

Postcode:

Telephone:

Email:

To the Manager of:

Branch address:

Please pay Mind in Kingston the sum of £ every month until I give you notice of termination in writing.
Starting on .
This replaces any existing Banker's Orders I have to Mind in Kingston.

My account number is .
My branch sort code is .
Signature Date

Payable to: Mind in Kingston
Branch Address:

Account Number:
Sort Code:

Thank you for your kind donation

Mind in Kingston Registered Charity No:1076791