PLEASE FILL IN THE FOLLOWING DETAILS AND THEN SECTION A OR B.

PLEASE REMEMBER TO SIGN THE DECLARATION BELOW.

(PLEASE COMPLETE IN BLOCK CAPITALS)




YOUR DETAILS
First Name:
Last Name:
Address 1:
Address 2:
Address 3:
County:
Postcode:
Telephone Number:
E-mail address:




Employer's Name:
Address 1:
Address 2:
Address 3:
County:
Postcode:
Work Telephone Number:
Employee/Staff Number:
N.I. number:

PLEASE NOTE:Your donation cannot be collected without this. You will find this number on your payslip




A) I would like to give a tax-free payroll donation.

Amount: £5£10£15Other £
Frequency: Weekly4-weeklyMonthly

B) I would like to increase my tax-free payroll donation.

From: £ To: £
Frequency: Weekly4-weeklyMonthly



DECLARATION

I authorise the sum indicated above to be deducted from my gross salary each payday as a gift to Combat Stress. I confirm I understand that no further tax is recoverable on this gift and that my total gifts to charity will not exceed the amount of income or capital gains tax that I pay in any tax year. This gift cannot be used as payment for any goods or services supplied.


Signed:    .................................................

Dated:      .........../.........../...........

PLEASE SEND THE COMPLETED FORM TO:

Director of Fundraising & PR
Fundraising Department
Combat Stress
Tyrwhitt House
Oaklawn Road
Leatherhead
Surrey, KT22 0BX

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