Please help us to raise £200,000+ to complete the accessible and sustainable refurbishment of our new building at 25 Wolsey Mews, NW5 2DX. If additional money is raised it will go towards our running expenses.

By donating regularly to Crossroads Women (www.crossroadswomen.net ), the tax paid on the sum donated can be claimed back by Crossroads Women, increasing its value at no extra cost to you.

To donate regularly by standing order through your bank, please fill in the forms below.

Title: ___ First name: _______________ Surname: ___________________________

Home Address: ________________________________________________________

_______________________________________________ Postcode: _____________

Phone:_______________ Email: __________________________________________

Instruction to your bank. (Please forward to my bank on my behalf.)

I wish to make a regular gift by standing order of £____every month starting ________ (Allow 28 days before first payment)

Signature: ______________________________ Today’s date ___________________

To (name of your bank): ______________________ At (branch address): __________

_____________________________________________________________________

Sort Code: __________________ Account number: __________________________

Sum to be credited to:

Account name: Crossroads Women Limited

Account number: 11683460

Bank: Lloyds TSB, 106 Kilburn High Rd, London NW6 4HY

Sort code: 30-94-71

Gift Aid Declaration

I would like Crossroads Women (charity no. 1134495) to reclaim the tax paid on my donations. I would like to Gift Aid all donations I make or have made since 6 April 2010 until further notice. I am a UK taxpayer and am paying an amount of tax equal to that Crossroads Women reclaims on my donations.

Signed:__________________________________ Today’s date: ___________2011

Please give return the original Instruction and Declaration (not a copy), keeping a copy for yourself, to:

Crossroads Women, Crossroads Women’s Centre

230a Kentish Town Road, London NW5 2AB

Crossroads Women, Registered charity no. 1134495, Company limited by guarantee no. 7087291