Justice Reflections - Standing Order Form

Justice Reflections Standing Order Form

Your Bank Details
To:	The Manager	Bank:		Branch Name:

1. Your Details
Your full name or name of organisation:
Your contact telephone number (including dial code):
Sort Code:	- -
Account Number:

2. Details of your Standing Order

Does this instruction replace any existing
standing order or direct debit instructions?

Yes

If yes please give details in special instructions below.

Recipient's Name:

JUSTICE REFLECTIONS

Recipient's Bank and Branch Name:

LLOYDS TSB, CARFAX, OXFORD

Recipient's Sort Code:

30 - 96 - 35

Recipient's Account Number:

02841383

First payment date (DD MM YY):

- -

First payment amount:
(if different from usual payment)

£ :

Usual payment amount:

£ :

Usual payment amount in words:

Final payment amount:
(if different from usual payment)

£ :

Final payment date:
(if applicable)

- -
- or tick if "Until Further Notice"

How often do you want the payment made?

Weekly

4 weekly

Monthly

Quarterly

Half yearly

Yearly

Other frequency
(please give details below)

Your payment reference: (if applicable)

Please give details of any special instructions:

Please allow up to three working days for funds to reach the recipient's account.

3. Your agreement with us

Please note that we will not:

-	make any reference to VAT or any other indeterminate element
-	advise your address to the person/organisation you are paying
-	tell the person/organisation you are not able to pay
-	tell the bank of the person/organisation you are paying to tell this person/organisation when payments are received

I/We authorise you to debit my/our account, in accordance with the details in Section 2

Your signature(s):

Date: