Standing Order Mandate

INSTRUCTIONS TO YOUR BANK OR BUILDING SOCIETY TO PAY A STANDING ORDER PAYMENT

To the Manager......................................................Bank / Building Society

Bank Address..............................................................................................................................

Postcode .......................

Name of account ................................................................................

Account No............................................... Sort Code......................

Please transfer from the above account to the Co-operative Bank:

Garrigill Village Hall, Account no. 65560705, Sort Code: 08-92-99

the sum of £.........(amount in words) .......................................................................pounds

commencing on...............................................and thereafter [annually on that date*] [on the 1st day

of each month*] [delete as appropriate] until this instruction is cancelled.

Using Reference : GVH100-....................................................................(add first initial and surname)

(Signature) ............................................................

(Name):..........................................................

(Address).....................................................................

...................................................................... (Postcode)......................

(Date) ..........................................

DO NOT SEND THIS FORM TO YOUR BANK OR BUILDING SOCIETY