Charity Gift Aid Declaration Boost your donation by 25p of Gift Aid for every £1 you donate Gift Aid is reclaimed by the charity from the tax you pay for the current tax year Your name & home address is needed to identify you as a current UK taxpayer To Gift Aid your donation you must complete all fields and select the option YES in the box below: I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all my donations in that tax year, it is my responsibility to pay any difference. I want to Gift Aid any current donation and any donations I make in the future or have made in the past 4 years to Guillain-Barré & Associated Inflammatory Neuropathies (GAIN): YesNo Date of declaration (DD/MM/YYYY):* Your name Your title:* Your first name:* Your surname:* Your home address House name or number and road:* Town or city:* Postcode:* Your email (so we can get back to you if we need to check information provided):* I have made a donation via JustGiving: YesNo If you have answered YES, please supply your JustGiving payment reference so we can claim Gift Aid on your donation My JustGiving payment reference is: Please notify the charity if you: • want to cancel this declaration • change your name or home address • no longer pay sufficient tax on your income and/or capital gains If you pay Income Tax at the higher or additional rate and want to receive the additional tax relief due to you, you must include all your Gift Aid donations on your Self-Assessment tax return or ask HM Revenue and Customs to adjust your tax code. I am happy to be contacted about your work and appeals via email: YESNO