Lloyds TSB Foundations
Matched Giving Scheme		 logo

Claim Form January to December 2010

We strongly advise that you read the guidance notes before completing this form

1   Your Details (BLOCK capitals please)

Title:

  

Forename:

  

Surname:

  

Payroll No:
 
 
 
 
 
 
 

Department/Branch:

  

Group Company: (eg LTSB, HBOS)
 
 
 

Work address:
 
 
           Postcode:   TNT:

Work contact tel no (direct line not network):

  

Work email address:
 
 
 
 

2  Your Claim

 
Amount raised or hours given
Amount claimed

Fundraising activity
£   
£   

Voluntary Time
            hours (@ £5 per hour)
£   

TOTAL CLAIM
£   
 

3  Charity Details

Charity name:

  

Registered charity no:
 
 
 

Charity address:
     
 Postcode:
 

4  Fundraising  activity:

Please describe how you raised the funds and what your role was:
 
  Date of the activity:

 

5  Voluntary time given

Please describe how you gave time to the charity:
 
 Date from:       Date to:
 

6 Claimant declaration

I declare that to the best of my knowledge and belief all the information I have provided in this application form is complete and true. I understand that any false or misleading statement or any significant omission may disqualify me from applying to the matched giving scheme and may render me liable to disciplinary action where dishonesty, theft or fraud are considered to be gross misconduct and may result in dismissal.

I consent to the above data being held and processed for the sole purpose of the matched giving scheme for Lloyds TSB Foundations. I also understand that my name, department, Group company and fundraising activity will be provided for information to the recipient charity in their award letter.

Claimant’s name:

  

Job title:
 
 
 

Claimant’s signature:

  

Date:
 
 
 
 

7 Line manager’s authorisation

To the best of my knowledge, the information given on this form is accurate and has been completed by a staff member of Lloyds Banking Group and I confirm that I am this staff member’s Line Manager.

Line manager’s name:

  

Job title:
 
 
 

Line manager’s signature:

  

Date:
 
 
 
 
Please send your completed form to:
   

staff based in the Channel Islands
Lloyds TSB Foundation for the Channel Islands
PO Box 160, 25 New Street
St Helier
Jersey JE4 8RG
TNT 13

 staff based in England & Wales
Lloyds TSB Foundation for England & Wales
Pentagon House
52-54 Southwark Street
London
SE1 1UN
TNT 89		 staff based in Northern Ireland
Lloyds TSB Foundation for Northern Ireland
2nd Floor, Cromac Place
Gasworks, Belfast
BT7 2JB