Survival International DIRECT DEBIT FORM

Registered charity: 267444

Please complete each section, and send to: SURVIVAL INTERNATIONAL, FREEPOST PAM 5410, LONDON EC1B 1EE

Yes, I want to make a regular gift to Survival International of 5 or 17th of every month quarter year
(minimum of 3 per month)

To start on: 1st YOUR DETAILS

(month). The start date must be within two months of date signed.

Dr/Mr/Mrs/Miss/Ms/Other (delete as applicable) First name Address Last name

Make your donation worth more at no extra cost to you. For every pound you give us, we receive an extra 25 pence from HM Revenue & Customs. So just tick here, its that simple! Please reclaim the tax on all donations I have made to Survival for the six years prior to this year, and any I make from now on. Please fill in
your name and address we need your full details to claim gift aid on your donation, thank you. You must pay an amount of UK income or capital gains tax at least equal to the tax we reclaim on your donations (currently 25p for every 1 you give).

Postcode Tel: E-mail: Please tick to receive occasional news from tribal peoples by e-mail.
SURVIVAL WILL NOT PASS ON ANY OF YOUR DETAILS TO ANY OTHER ORGANISATION

INSTRUCTION TO YOUR BANK OR BUILDING SOCIETY TO PAY DIRECT DEBIT

Name(s) of account holder(s) Originators identification number: Bank/Building Society account number:
Instruction to your Bank/Building Society Please pay Survival International Direct Debits from the account detailed in this instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this instruction may remain with Survival International and, if so, details will be passed electronically to my Bank/Building Society.

Branch Sort Code:

Name and full postal address of your Bank or Building Society

To: The Manager Bank/Building Society Address

Your signature(s)

Date Postcode
BANKS AND BUILDING SOCIETIES MAY NOT ACCEPT DIRECT DEBIT INSTRUCTIONS FOR SOME TYPES OF ACCOUNTS
>> PLEASE DONT FORGET TO SIGN AND DATE THIS FORM <<

Ref. number (for office use only)

THIS GUARANTEE SHOULD BE DETACHED AND RETAINED BY THE PAYER

THE 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 to the amount, date or frequency of your Direct Debit Survival International will notify you 10 working days in advance of your account If an error is made in the payment of your Direct Debit by Survival International or your bank or building society you are entitled to a full and immediate refund 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.
of the amount paid from your bank or building society If you receive a refund you are not entitled to, you must pay it back when Survival International asks you to time of the request being debited or as otherwise agreed. If you request Survival International to collect a payment, confirmation of the amount and date will be given to you at the

T 020 7687 8700 F 020 7687 8701 E info@survivalinternational.org www.survivalinternational.org

Survival International, 6 Charterhouse Bldgs., London EC1M 7ET, UK