TEST EMBED FORMASSEMBLY WED – Solace Womens Aid

Donation Form

Campaign

Donation Details

Donation Type

One-OffRecurringPay In FundraisingCompany Donation

Frequency

MonthlyQuarterlyYearly

Donation Amount

£6£12£40Other

Recurring Donation Amount

£4£9£22Other

Amount

Donation Reference

If you’ve been given a payment reference code by our fundraising team, please enter it here

Event Description

Tell us a bit more about your event/fundraiser

Add 25% to your Donation by Gift Aiding it

Yes, I want to Gift Aid my donationI am not a UK TaxpayerTick the box above and Solace Women’s Aid will claim 25% extra on your donation from the government. Please provide the address needed to identify you as a current UK taxpayer. Please notify the Charity if you want to cancel this declaration, change your name of home address and/or 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 your Gift Aid donations on your Self-Assessment tax return or ask HM Revenue and Customs to adjust your tax code.

Your Information

Title

First Name

Last Name

Phone Number

We will only use your Phone Number if we need to contact you about this Donation.

Email Address

Address – please ensure this is the billing address for the card being used.

Company Name

Street 1

Street 2

City

Post Code

Country

Keeping in Touch

We’d love to keep you updated with our life-saving work, how you can make a difference and ways to get involved. Please let us know if you’re happy to hear from us by email and remember you can change your preferences or unsubscribe at any time. We promise to keep your details safe and never sell or swap them with anyone. Our privacy policy explains how we keep this promise.

Count me in

YesNo

Please let us know what you’re interested in hearing about:

Solace News	Supporting Our Work
Volunteering	Training and Consultancy

Page 3

How would you like to pay?

Credit CardDirect Debit

Payment Information

Name on Card

Credit Card Number

CVC

Expiry Month

Expiry Year

Bank Details

Instructions to your bank or building society

Please pay Stripe Direct Debits, from the account detailed in this instruction subject to the safeguards assumed by the Direct Debit guarantee.

I understand that this instruction may remain with Stripe and if so, details will be passed electronically to my bank/building society.

Banks and Building Societies may not accept Direct Debit Instructions for some types of accounts.

Day of the Month

115

Account Holder Name

Sort Code

Account Number

Bank/building society address

I verify that I am authorised to set up a Direct Debit on this account

Yes

Direct Debit Guarantee

This guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits.

If there are any changes the amount, date or frequency of your
Direct Debit, Stripe will notify you 10 working days in advance of
your account being debited, or as otherwise agreed. If you request
Stripe to collect a payment, confirmation of the amount and date
will be given to you at the time of request.

If an error is made in the payment of your Direct Debit by Stripe 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 full refund you are not entitled to, you must pay it back when Stripe 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.

Solace Women’s Aid uses Stripe to process Direct Debits on our behalf.

Your donation will appear on your statement as Solace Women’s Aid.

Contact Information