FUTURE POLKA FOUNDER / FAMILY Pledges & Donations Form

FOUNDER / FAMILY PLEDGES AND DONATIONS FORM Please complete the following steps: 1.

2.

3.

Choose if you’d like to become a FOUNDER or FAMILY supporter Fill in both sides of this form, including tick boxes Return form By post to Amanda Cropper, Capital Campaign Director, Polka Theatre, 240 The Broadway, London SW19 1SB By email to amanda@polkatheatre.com

I/Our family would like to support Polka’s capital appeal to improve the theatre for future generations by becoming a

FUTURE POLKA FOUNDER Total payment to be made in agreed instalments within 3 years by

One-off gift (£10,000)

FUTURE POLKA FAMILY Total payment to be made in agreed instalments within 3 years by One-off gift (£3,000)

Annual donation (£3,333)

Annual donation (£1,000)

Monthly payment (£278)

Monthly payment (£83)

My/Our preferred method of payment is Online bank transfer

Credit/debit card

Cheque

CONTACT DETAILS

Title

First name:

Last name: Address:

Town/city: Postcode: Telephone: Email: Data Protection – Polka Theatre is committed to protecting your personal information, which will be stored securely and used for administering your FUTURE POLKA donation. For our full Privacy Policy, visit polkatheatre.com/privacy policy

Make your donation worth 25% more at no extra cost to yourself. By using Gift Aid we will receive an extra 25p from HMRC on every £1 you give.

I am a UK taxpayer and I want Polka Theatre to reclaim the tax on all qualifying donations made for the four past years prior to this date and all further gifts I make from the date of this declaration – until I notify you otherwise. I confirm that I am a UK tax payer and have paid or will pay an amount of Income Tax and/or Capital Gains Tax for each tax year (6 April to 5 April) that is at least equal to the amount of tax that all the charities or Community Amateur Sports Clubs (CASCs) that I donate to will reclaim on my gifts for that tax year. I understand that other taxes such as VAT and Council Tax do not qualify and that if I pay less Income Tax an or Capital Gains Tax than the amount of Gift Aid claimed on all my donations in that tax year it is my responsibility to pay any difference.

I will inform you should my tax status, name or address change.

RECOGNITION I/We would like to be credited as I/We would prefer to remain anonymous

Example: The Doran family

IF YOU WISH TO MAKE YOUR GIFT CONDITIONAL My/our donation is to be used in support of the Future Polka capital redevelopment project. If it is not possible to use my/our gift for this purpose (please tick box as appropriate): I/We wish it to be used for other purposes of Polka Theatre and its young audiences I/We wish you to discuss the matter with me/us I/We wish you to return the money to me/us Signature

Date

Please return this completed form to: Amanda Cropper, Polka Theatre via the postal or email address on the front of this card.

Thank you from Polka and our young audiences of the future for your wonderful support!

Polka Children’s Theatre is registered as a charity no. 256979 and as limited company no. 938592.