Gift Aid Declaration

ROMAN  CATHOLIC  DIOCESE  OF  SOUTHWARK
OUR LADY OF PITY and ST SIMON STOCK – PUTNEY
TITLE:  (Mr/Mrs/Miss/Ms)    (Please delete as appropriate)
SURNAME: (Block Capitals)
FORENAME(S): (Block Capitals)
HOME ADDRESS: (Block Capitals)
POST CODE:
Telephone No(s)
E-Mail Address
Please treat:
* all gifts of money that I make today and in the future as Gift Aid donations; OR
* all gifts of money that I have made in the past 4 years and all future gifts of money that I make from the date of this declaration as Gift Aid donations. 
*(Please tick the appropriate box)
I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all my donations in that tax year, it is my responsibility to pay any difference to HMRC.
Signature  ………..…………………………………Date  ..………………………………….
Gift Aid is reclaimed by the charity from the tax you pay for the current tax year.  Your address is needed to identify you as a current UK taxpayer.
Please notify the charity if you:
1 Want to cancel this declaration.
2 Change your name or home address.
3 No longer pay sufficient tax on your income and/or capital gains.
If you pay income tax at the higher or additional rate and want to receive the additional tax relief due to you,  you must include all your Gift Aid donations on your Self Assessment tax return or ask HM Revenue and Customs to adjust your tax code. 
Oct 15 Parish Code: EC Env. No.                                  GAD No.