Customer Ref:


Until further notice

Payment Information

Payment Day:
First Payment Date:
15 May 2019
I wish to pay a regular Direct Debit of:

Personal Details


Additional Information


Instruction to your Bank or Building Society to pay by Direct Debit

Eazy Collect Re Air Ambulance, 3rd Floor, County Gates, Ashton Road, Bristol, BS3 2JH

Service User Number:


Checking the box indicates that I am the Bank/Building Society holder and no authority other than my own is required. If more than one person is required to authorise debits from the account, you are unable to setup a direct debit online.

Yes! I want my donation to go further. Please treat as Gift Aid donations all qualifying gifts of money I have made in the past 4 years and any I will make in the future By ticking the box I confirm I have paid or will pay an amount of Income Tax and/or Capital Gains Tax for each tax year (6 April to 5 April) that is at least equal to the amount of tax that all the charities or Community Amateur Sports Clubs (CASCs) that I donate to will reclaim on my gifts for that tax year. If I pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all my donations in the tax year, I understand that it is my responsibility to pay any difference. I understand the charity will reclaim 25p of tax on every £1. I understand that other taxes such as VAT and Council Tax do not qualify. Please notify the charity if you want to cancel this declaration, change your name or home address and /or no lon ger pay sufficient tax on your income and/or capital gains.




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