Paying in Slip

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Donation Form

DETAILS Full name (please print):....................................................................................................

Address: .................................................................................................................................

Postcode: ....................................... Phone ......................................................................

Email Address...................................................................................................................

WISH Please tell us here where you want to help:

 Royal Sussex County Hospital

 Royal Alexandra Children's Hospital

 Sussex Eye Hospital

 Princess Royal Hospital

 Other (particular ward, department or project): ....................................................................

HOW One off donation:

I would like to donate £ ................................. (please make cheques payable to BSUH Charity)

Regular Gift ­ Become a Hospital Hero
By becoming a Hospital Hero, you will be helping our four hospitals by providing monthly support we can count on, ensuring our preparedness for emergencies, and helping patients now and in the future.

I would like to give a regular sum of: £3  £5  £10  £20  Every month  Quarterly  Until further notice. Starting immediately  or on: ____/_____/_______ (insert date)

£50 

Other £ ...........

Bank Details for Regular Gift My Bank name........................................................................... Address ................................................................................... ............................................................................................... ......................................................... Postcode ........................ Account name (your name or business name) ................................. Account number .................................. Sort Code .......................

Please pay Brighton and Sussex University Hospitals NHS Trust Charitable Fund the sum indicated above. Nat West Bank PLC, RBS Group 2nd Floor, 280 Bishopsgate, London EC2M 4RB Account: 10012915 Sort: 60 70 80

Gift Aid ­ Boost your donation by 25p of Gift Aid for every £1 you donate. 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.
In order to Gift Aid your donation you must tick the box below.

I want to Gift Aid my donation of £________ and any donations I make in the future or have made in the past 4 years to Brighton & Sussex University Hospitals NHS Trust Charitable Fund. 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.

Please notify the charity if you: · want to cancel this declaration · change your name or home address · no longer pay sufficient tax on your income and/or capital gains
Donor Signature: ________________________________________ Date: ____________________

Please return completed forms to: BSUH Charity, Royal Sussex County Hospital, c/o Post Room, Eastern Road, Brighton BN2 5BE

Thank you very much for your kind donation.

BSUH Charity, Royal Sussex County Hospital, c1/o Post Room, Eastern Road, Brighton BN2 5BE Charity Registration No. 1050864 www.bsuh.nhs.uk/charity E: Charity@bsuh.nhs.uk P: 01273 664708