Please print this form and send to:­

CLACTON & DISTRICT STROKE ASSOCIATION
85 FRINTON ROAD
HOLLAND ON SEA
ESSEX
C015 5UH
TELEPHONE: 01255 815905   FAX: 01255 815905
Registered Charity Number 1054049

I would like CLACTON & DISTRICT STROKE ASSOCIATION to reclaim tax on:
  -The enclosed donation.
  -All donations I have made since April 6th 2000, and all donations I make from the date of
    this declaration until further notice.
  -All donations I make through my standing order form.
  -(delete as appropriate.)
 

Full Name         ___________________________
Address:          ___________________________
                        ___________________________
                        ___________________________
                        ___________________________
Post Code:        ___________(this must be included)
Date:                _____/_____/_____
Signature:        ___________________________
 

Notes:
  -You must pay an amount of income tax or capital gains tax at least equal to the tax
   we reclaim on your donation in any tax year (currently 28p for every £1 you give).
  -You can cancel this declaration at any time by notifying CDSA.
  -If in the future your circumstances change and you no longer pay tax on your income
   and capital gain equal to the tax that we reclaim, you can cancel your declaration.
  -If you pay tax at the higher rate you can claim further tax relief in your Self
  -Assessment tax return.
  -If you are unsure whether your donations qualify for Gift Aid tax relief, ask CDSA
   or ask your local tax office for leaflet IRI13 Gift Aid.
  -Please notify CDSA if you change your name or address.

Thank you for support.