Please fill in the whole form including official use box using a ball point pen and send it to:
Headway The Brain Injury Assoc
Bradbury House
190 Bagnall Road
Old Basford
Nottingham
NG6 8SF
Name(s) of Account Holder(s)
 
 
Bank / Building Society Account Number
               
Branch Sort Code
           
Name and full postal address of your Bank or Building Society
 
Reference
 

Instruction to your Bank or Building Society to pay by Direct Debit
Service User Number
838982

FOR Headway The Brain Injury Assoc OFFICIAL USE ONLY This is not part of the instruction to your Bank or Building Society IMPORTANT - Please complete these details:
Account Holder(s) Name & Address
Name:
Contact name  First: Last:
Address:
 
Town: Postcode:
Email Address:
 
Instruction to your Bank or Building Society
Please pay Headway Brain Injury Assoc Direct Debits from the account detailed in this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with Headway Brain Injury Assoc and, if so, details will be passed electronically to my Bank / Building Society.
Signature(s)


Date:

Banks and Building Societies may not accept Direct Debit Instructions for some types of account.

This Guarantee should be detached and retained by the payer.
The Direct Debit Guarantee
  • This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits.
  • If there are any changes to the amount, date or frequency of your Direct Debit Headway Brain Injury Assoc will notify you 10 working days in advance of your account being debited or as otherwise agreed. If you request Headway Brain Injury Assoc to collect a payment, confirmation of the amount and date will be given to you at the time of the request.
  • If an error is made in the payment of your Direct Debit, by Headway Brain Injury Assoc or your bank or building society you are entitled to a full and immediate refund of the amount paid from your bank or building society.
    - If you receive a refund you are not entitled to, you must pay it back when Headway Brain Injury Assoc asks you to.
  • You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.

Print