Please COPY AND PASTE this form into an email
or PRINT and send it to:

House of Good Health,
10 Gibson Gardens, London N16 7HB

I want the charity to treat
*the enclosed donation of £ ……………….
*the donation(s) of £ ………………………which I made on ……/……/……..

*all donations I make from the date of this declaration until I notify you otherwise
as Gift Aid donations.

Details of donor

Title         Forename(s)                                                       Surname

Address
 

Post Code

Name of Charity: House of Good Health
 
Notes
1. You must pay an amount of income tax and/or capital gains tax at least
equal to the tax that the charity reclaims on your donations in the tax year
(currently 28p for each £1 you give).
2. You can cancel this declaration at any time by notifying the charity.
3. If in the future your circumstances change and you no longer pay tax on your
income and capital gains equal to the tax that the charity reclaims, you can
cancel your declaration (see note 1).
4. If you pay tax at the higher rate you can claim further tax relief in your Self-
Assessment tax return.
5. If you are unsure whether your donations qualify for Gift Aid tax relief, ask the
charity. Or ask your local tax office for leaflet IR 65.
6. Please notify the charity if you change your name or address.