Date. . . . . . . . . . . . . . . . . . . . .

To. . . . . . . . . . . . . . . . . . . . . . . . . . . . Plc
(Name of your bank)

Branch Address:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Branch Sort Code:

Starting on the. . . . . .(day) of . . . . . . . . (Month / Year) and on the same day *yearly / half yearly / quarterly / monthly 
for the next . . . . . . . . . . . years, please pay the sum of

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (amount in words)

£ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(amount in figures)

*To the Dyslexia Institute (Sort Code 30-94-42 A/c No 03194907)
or The Dyslexia Institute Bursary Fund (Sort Code 30-94-42A/c No 03195121)
(*Please delete as appropriate)
at LloydsTSB Bank Plc,
215 High Street, Hounslow, Middlesex, TW3 1DN

Signed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

               . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

               . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
 

Post Code. . . . . . . . . . . . . . . . . . . . . 

Bank Account no. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Please Print and complete this form then send it to your bank
Please send a copy of the form to:

In order for us to claim the tax back from the Inland Revenue you must pay an amount of income tax and or capital gains tax at least equal to the tax that the Dyslexia Institute or the Dyslexia Institute Bursary Fund reclaims on your donation in the tax year.