(Please write in CAPITAL LETTERS)

To: The Manager (please insert the details of your bank branch, name, and address below)

Name of Account

Bank Sort Code Account number

[__ __]__ __]__ __] [__]__]__]__]__]__]__]__]__]__]__]__]

Your Instruction to your Bank or Building Society

Please pay the amount indicated below to Chimteka Children Support account at Bank of Ireland, Sutton, Dublin 13

Branch Sort Code 90-06-90 Account Number 10378103

I would like to donate the sum of €. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (amount in figures

and words) to Chimteka Children Support every week/month/quarter/year* (please delete as appropriate) until further notice. I would like the first payment to start from . . . . . . . . . . . . . . . . . . . (please enter the date you would like the first payment to be made. We suggest you allow at least one month between the date of signing the form and the first payment).

Name:

Address:

Email: ___________________________________ Tel No:

I authorise you to debit my/our account in accordance with the details above.

Signed: Dated:

This request is addressed to the bank, which holds my/our account.

Please return to: Paul McDonald, Chimteka Children Support, 21 Fintan’s Park, Sutton, Dublin 13

THANK YOU