(Please print and post this completed form to your bank)

To: .............................................................................................................(name of your bank)

Address: ................................................................................................................................

......................................................................................................(address of your bank)

Post Code: ...........................................(post code of your bank)

Please pay: National Westminster Bank, 45 London Street, Norwich, NR2 1HX,
Sort Code: 60-15-31 For the credit of the LCA, account number: 23740116

the sum of £ .............. (in figures) |  ...........................................................(amount in words)

commencing ........ /....... /200..... , and monthly thereafter until further notice.

From me / us in writing

debiting my / our account number: .......................................................................... accordingly.

Signed: ..................................................................................... Date: ........ /....... /200.......

Signed (For Joint Accounts) : .................................................... Date: ........ /....... /200.......

Name: ..................................................................................................................(your name)