Direct Debit Form
How your gift will help
Dementia UK oers specialist one to one support and expert advice for families living with dementia through our
Admiral Nurses. Your regular donation will help us provide more support to families that need it.Thank you.
My details
You can also complete this form online at www.dementiauk.org/donate
or call us on 0300 365 5500 to set up your gift over the telephone
Instruction to your Bank or Building Society to pay by Direct Debit
Please complete sections 1-5 and then return the form to:
Dementia UK, Freepost RTZS–HCZL–RTUT, 7th Floor, 1 Aldgate, LONDON EC3N 1RE
Registered charity in England and Wales (1039404) and Scotland (SC047429)
Title: Forename: Surname:
Home address:
Postcode:
Tel no: Email:
Branch sort code:
Name and full postal address of your Bank or Building Society:
Bank/Building Society account number:
The Direct Debit Guarantee
This Guarantee is oered by all banks and building societies that accept instructions to pay Direct Debits.
• If there are any changes to the amount, date or frequency of your Direct Debit Dementia UK will notify you 10 working days in advance of your account being debited or as otherwise
agreed. If you request Dementia UK to collect a payment, confirmation of the amount and date will be given to you at the time of the request.
• If an error is made in the payment of your Direct Debit, by Dementia UK or your bank or building society you are entitled to a full and immediate refund of the amount paid from
your bank or building society. If you receive a refund you are not entitled to, you must pay it back when Dementia UK asks you to.
• You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.
I would like to give £ per month /quarter / year (delete as appropriate) starting on 1
st
/ 15
th
(delete as appropriate)
month year (allow one month from today)
1
2
3
4
5
Banks and Building Societies may not accept Direct Debit Instructions for some types of account
Service User Number
Reference For Dementia UK use only
Instruction to your Bank or Building Society
Please pay Dementia UK Direct Debits from the account detailed
in this instruction subject to the safeguards assured by the Direct
Debit Guarantee.
I understand that this instruction may remain with Dementia UK and,
if so, details will be passed electronically to my Bank/Building Society.
5 0 4 1 9
8
Name(s) of account holder(s):
Name of Bank:
Address:
Postcode:
To the Manager
Signature(s):
Print name:
Date:
Gift Aid makes every £1 worth at least £1.25
to us at no extra cost to you!
Keeping in touch
I am a UK tax payer. Please treat all donations I make or have made to Dementia UK
for the past four years as Gift Aid donations until further notice.
I understand that if I pay less Income Tax and/or Capital Gains Tax than the amount of
Gift Aid reclaimed on all my donations in that tax year it is my responsibility to pay any
dierence. Gift Aid is reclaimed by the charity from the tax you pay for the current tax year.
Please contact our Supporter Care Team on 0300 365 5500 if you want to cancel this
declaration, if you change your name or home address, or if you no longer pay sucient
tax on your income and/or capital gains.
Date:
Your support is a lifeline to families facing dementia.
We’d like to keep you updated about how your support
is making a dierence, and how can you can continue to
support our life changing work.
Yes, I would like to be updated by email.
Email:
Yes, I would like to be updated by phone.
Phone no:
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