Donation Form
Celebrate the life of someone very special to you...
Your donation - please tick the relevant box £19.63 which could pay for one hour's nursing care in our In-Patient Unit £50 typically pays for families to stay for 2 nights in our "Wee House"
£100 would help towards a home visit by our Specialist Palliative Community Nursing Team £235.56 is enough to pay for the care of 1 patient in our In-Patient Unit on Christmas Day or another amount of £ Your Information The following information is required in order for us to record your donation. Please complete as fully as possible.
Title (Mr, Mrs, Ms, Other)____________________ Name_ __________________________________
Address (incl. town & postcode)_______________________________________________________
_________________________________________________________________________________
Email____________________________________ Tel_ _____________________________________
Payment Details
Gift Aid your donation! It will boost your donation by 25p of Gift Aid for every £1 you donate. Gift Aid is reclaimed by Ayrshire Hospice from the tax your pay for the current tax year. Your address is needed to identify you as a current UK taxpayer. In order to Gift Aid your donations, you must tick the box below: I want to Gift Aid any donations I make in the future or have made in the past 4 years to Ayrshire Hospice. 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.
I enclose a cheque made payable to Ayrshire Hospice
Please debit my: Visa
Maestro
Mastercard
Delta
Card Number
Valid From
Expiry Security Code Issue No. (Maestro Only)
Cardholder's Signature_ ___________________ Date:___________________________________
Return your completed form to Ayrshire Hospice Fundraising Office, 29 Miller Road, Ayr, KA72AX. Registered Charity No SC011390
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