Title: Name: Phone:

Address: Postcode:

Email: Company:

Sponsorship FormI'm taking part in ...................................................

for St Richard's Hospice. Please help me raise ...........

Are you a UK taxpayer?Turn every £1

in to £1.25 without

spending an extra

penny!

Make it easier for people to support your fundraisingand donate online. Set up your own Just Giving page atwww.justgiving.com then enter your page name here

House name or no. Postcode Amountdonated

Gift Aid

DateCollected

First name and Surname This is essential for Gift Aid- please do not use your work address £ 10.00 25/12/2019

Full Name House name or number

Postcode Amount donated Gift Aid DateCollected

£5 could pay fora delicious andnutritious mealfor a patient

£11.54 could pay fora Hospice at HomeHealthcare Assistantfor an hour*

£14.92 could pay fora patient to receiveone ComplementaryTherapy treatment

*(this is the full cost of employing a Hospice at Home Healthcare Assistant and all on-costs including national insurance, pension contributions)

If I have ticked the box headed ‘Gift Aid? √’, confirm that I am a UK Income or Capital Gainstaxpayer. I have read this statement and want the charity namedabove to reclaim tax on the donation detailed below, given on thedate shown. I understand that if I pay less Income Tax / orCapital Gains tax in the current tax year than the amount of GiftAid claimed on all of my donations it is my responsibility to payany difference. I understand the charity will reclaim 25p of tax onevery £1 that I have given.

3 easy ways to pay in your money Online at www.strichards.org.uk/donate

By post making your cheque payable to 'St Richard'sHospice' to Fundraising Department, St Richard'sHospice, Wildwood Drive, Worcester WR5 2QT

Come and see us at the Hospice or one of our shops

Do you have a ForgetMe Not tribute fund? If so please let us knowand the reference:

Full Name House name or number Postcode Amount donated Gift Aid DateCollected

First name and Surname This is essential for Gift Aid- please do not use your work address £ 10.00 25/12/2019