200 Club Mandate Form

Bank Name(Required)

Branch Address(Required)

Donation Amount(Required)

Please pay to the account of the Sheriffs’ & Recorder’s Fund, a/c no. 10842508, sort code 20-10-53, Barclays Bank PLC, Bloomsbury & Tottenham Court Road Branch, PO Box 113345, London W12 8GG to the sum of (suggested minimum £200):

Donation Start Date(Required)

Please enter your desired date for your first donation, this will repeat annually until further notice.

Name(Required)

Prefix First Last

Address(Required)

Home Address Address Line 2 City County Post Code

Email(Required)

Bank Account Number(Required)

Sort Code(Required)

Mandate Signature(Required)

Gift Aid Declaration(Required)

I should like the Sheriffs’ & Recorder’s Fund (Charity Commission reference 221927) to reclaim the tax I have paid on this donation, and on all future donations. I am a UK taxpayer and note that I must have paid at least as much income tax or CGT as will be reclaimed. Please treat this and all future payments as Gift Aid donations.

Yes

Gift Aid Signature(Required)