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Gift Aid declaration form

Gift aid logo Make your donation go further at no extra cost to you. Gift Aid is a Government run scheme that allows us to reclaim the tax on your donation. For every £1 you donate, we get an extra 28p back, making your donation go further at no extra cost to you.

You must pay an amount of UK Income Tax and/or Capital Gains Tax at least equal to the tax that the charity reclaims on your donations in the appropriate tax year.

Please tick the box below to join the Gift Aid scheme.

If you prefer to print out the form and send it to us, you can use this version.

* denotes a required field

Please reclaim tax on: (tick one box)

I want Samaritans to treat all donations I make from April 6 2000, until I notify you otherwise, as Gift Aid donations. *

Your Name

Title: *

Forename: *

Middle Name:

Surname: *

Date of birth (DD-MM-YYYY)

Your Address

House/Building number or name: *

Address: *

Town or City: *

County: *

Postcode: *

Country:

Your contact details

Telephone number:

Telephone is:

Email Address:

If you are not a taxpayer, please tick this box

Data Protection Policy

Link to Data Protection Policy

When you make a donation, we will add your name and address to Samaritans' list of supporters, so that from time to time we can send you further information. If you would prefer that we do not contact you, please tick this box.

Samaritans can sometimes benefit by allowing other organisations to write to our supporters. We do occasionally exchange names with carefully selected organisations. If you would prefer your name not to be included, please tick this box.

Signed

Today's Date: *

You can cancel this declaration at any time by writing to us, for example if you cease to pay tax, but while the declaration is in force, please let us knows if you change your name or address. Remember to notify us if you no longer pay an amount of income tax and/ or capital gains tax equal to the amount of tax that we reclaim on your donations. If you are not sure whether your donations qualify for Gift Aid tax relief, please contact us, or ask your local tax office for leaflet IR113 Gift Aid.