Please print this form and complete in block capitals and post to the following address.

The Service Manager
Stonecroft House Cheshire Home
Barnetby
North Lincolnshire
DN38 6DY

Yes, I want to make a difference by supporting disabled people.
Please do not send cash.

I enclose the sum of £ _ _ _ _ _ _ _ _ _ _ _ _ as a donation to the Stonecroft House general fund.

Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Postcode: _ _ _ _ _ _ _ _ _ _ _ _

Telephone: (optional) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

E- mail: (optional) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Signed: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Please make cheques payable to Stonecroft House

Thank you for your donation to Stonecroft House.

Gift Aid form

Yes, I would like Leonard Cheshire to treat all my donations from 6 April 2000 until further notice as Gift Aid. I confirm I am a UK income or capital gains tax payer and the amount of tax I pay each tax year exceeds the amount I would like Leonard Cheshire to claim.

Signed _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date _ _ _ _ _ _ _ _ _ _ _ _ _ _

No, I do not pay tax in the UK and cannot gift aid my donation.

From time to time we may contact you with information on other ways that you can help Stonecroft House Cheshire Home or Leonard Cheshire. If you do not wish to receive this information, please tick _ _ _ _ _

If you are happy to receive this information by e-mail, please tick _ _ _ _ _

Stonecroft House Cheshire Home & other parts of Leonard Cheshire will not pass your details to any other organisation.