| GIFT FORM |
|---|
| From: (Mr. Mrs. Ms. Miss) |
| Address: |
| Postcode: |
| Please complete your name and address or telephone your credit card gift to 01444 457080 |
| I would like to support The Lake Clinic-Cambodia. Here is my gift of £ |
| I wish to use my credit card: Access/Mastercard/Barclaycard/Visa/CAF |
| Credit Card No.: |
| Expiry Date: / Telephone No*.: |
| Security Code (last 3 digits on reverse of card): |
| Signature: |
| I am a
UK tax payer and I wish all donations I have made to the IMPACT foundation
in the last four years and all donations I make hereafter to be treated as Gift
Aid donations (please tick). Today's Date / / |
| I am not a UK Taxpayer |
| Please remember to notify us if you no longer pay an amount of income tax or capital gains tax equal to the tax we claim on your donations (28p for every £1 you give), or if your name or address changes. You may cancel this declaration at any time by writing to us. |
| Please cross cheques and postal orders and make them payable to the IMPACT Foundation |
| Please send
me more information about: IMPACT Leaving a Legacy Tax-effective Giving Donating Shares |
Please return to: Mrs. Judi Stagg, Chief Executive IMPACT/TLC, 151 Western Road, Haywards Heath, West Sussex, RH16 3LH, UK. Registered Charity No. 290992. |
| Thank you |
* For your security, we may need to telephone you to confirm your credit card gift.