Gift Aid Form

Text Box: Please complete this form and return with your donation to:
Northern Ireland Leukaemia Research Fund Office, Haematology Department, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB. Telephone 028 90 322603 Text Box: Note: You must pay an amount of Income Tax and/or Capital Gains Tax, at least equal to the Tax we reclaim on your donations. Text Box: Full Name: ___________________________ Title: _______
Address: ________________________________________
Postcode: _____________
Amount given: £________ Date: ____________________ Text Box: I am a UK Taxpayer and would like the Northern Ireland Leukaemia Research Fund to reclaim Tax on the enclosed gift. Text Box: You can add nearly 30 per cent to the value of your gift simply by filling in your name and address and printing and returning this form to us.
Please treat my donations as Gift Aid Donations. Text Box: Gift Aid It Text Box: Northern Ireland Leukaemia Research Fund
www.leukaemia-ni.org