FO-CY266-B

CHARITY
RECIPIENT
DECLARATION
H.M. FOREIGN
OFFICE

For use in compliance with the Charity And Donation Transfer

Regulations 2007, as amended by statute, for all donations FROM the
United Kingdom, Isle of Man, Channel Islands and related territories TO
non EU-Member States.

FO-CY266-B
Revision 3 (01/08)

H.M. FOREIGN OFFICE | CY266-B | 3(01/08) 1

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CHARITY
RECIPIENT
DECLARATION
H.M. FOREIGN
OFFICE

© Crown Copyright 2007

Published with the permission of HM Foreign Office

on behalf of the Controller of Her Majesty’s
Stationery Office

The text in this document, excluding the Royal

coat of arms and all departmental logos is
copyright © Her Majesty’s Government and may
not be reproduced without permission.
Unauthorised reproduction may result in civil
and/or criminal prosecution.

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CHARITY
RECIPIENT
DECLARATION
H.M. TREASURY

This page is blank.

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CHARITY
RECIPIENT
DECLARATION
H.M. FOREIGN OFFICE

RECIPIENT PERSONAL DETAILS

This column is for
official use only

Your Name

Your Address

Postcode/Zipcode Country of Residence

Telephone Number
+
E-Mail Address

To The Transferee What you have to do

The charity recipient declaration form is a  Print this form IN FULL COLOUR
requirement of the British Government and requires
that all recipients of charity from donors in the United  Complete all sections in BLACK ink
Kingdom complete and submit the form to HM
Foreign Office BEFORE any charitable donation is  Attach Two (2) passport photographs in the
received. This acts as a guarantee that all taxes and sections indicated
disbursements have been correctly paid on the
donation , that appropriate oversight as to the source  Make the necessary fingerprint identifications in
of funding is maintained and that proper records can the sections indicated
be kept for the purposes of the prevention of
terrorism, money laundering and other requirements  Sign and date the form in the location indicated
under international law.
 Return the form to the benefactor (the person
You must complete this form fully and completely and who is making the donation) within Three (3)
honestly. Deliberate falsification of any information days of receipt.
you submit on this form is a criminal offence and may
result in a fine, imprisonment or both

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 CHARITY
RECIPIENT
DECLARATION
H.M. FOREIGN OFFICE

PHYSICAL IDENTIFICATION

Insert Two (2) passport sized photographs of yourself in the spaces below

IMPORTANT: The photographs above MUST meet international standard passport photograph standards. If in doubt
as to the standard we require please consult your nearest passport office or read the guidance notes at the Home
Office Identity and Passport Service website http://www.ips.gov.uk/passport/downloads/photos.pdf

In the space below add your finger/thumb prints as indicated

Left Index Finger Left Thumb Right Index Finger Right Thumb

You should use BLACK ink to make the finger and thumb print impressions, please ensure that the impressions are
clear and free from smudges, marks, omissions or taints.

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CHARITY
RECIPIENT
DECLARATION
H.M. FOREIGN OFFICE

CHARITY RECIPIENT DETAILS

FOR OFFICIAL USE ONLY
Name of charity

Address

Postcode/Zipcode Country

Telephone Number
+
E-Mail Address

In which country is the main headquarters of the charity located?

What is the registration number of the charity?

If the charity has a religious base, which religion is it?

Does this charity seek to carry out religious conversion or indoctrination? Yes No

Does anything in the constitution of the charity advocate violence? Yes No

Does anything in the constitution of the charity advocate discrimination

against women, homosexuals, people from other religions, races or tribes,
zoophiles, transgendered individuals, disabled people or other animal species ? Yes No

Does the charity have an equal opportunities policy? Yes No

Has the charity ever been expelled or forbidden from working in any country? Yes No

Has the charity even been accused or convicted of terrorism or supporting terrorism? Yes No

Has the charity ever been accused or convicted of any criminal offences? Yes No

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 CHARITY
RECIPIENT
DECLARATION
H.M. FOREIGN OFFICE

Please give full details of what the purpose and primary objective of the charity is (use a separate sheet if
necessary)

H.M. FOREIGN OFFICE | CY266-B | 3(01/08) 7

 CHARITY
RECIPIENT
DECLARATION
H.M. FOREIGN OFFICE

Please explain IN DETAIL what you will use the charitable donation you will be receiving for (Use a
separate sheet if necessary)

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 CHARITY
RECIPIENT
DECLARATION
H.M. FOREIGN OFFICE

How much money was donated to the charity in the past 12 months (per currency)
Currency Amount

Currency Amount

Currency Amount

Currency Amount

Currency Amount

Currency Amount

Currency Amount

How is the current donation being transferred to the charity?

Bank Transfer Courier Wire Transfer (e.g. Western Union) Other

Please give full details of bank accounts, WU collection agencies, etc to be used

Will taxes be paid on this donation?

Yes No

If you have answered “NO” above, please indicate why taxes will not been paid

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CHARITY
RECIPIENT
DECLARATION
H.M. FOREIGN OFFICE

CRIMINAL / TERRORISM DECLARATION

Have you ever been charged or convicted for any money laundering offences? Yes No

Have you ever been charged or convicted for fraud, embezzlement or advanced fee fraud? Yes No

Have you ever been declared bankrupt? Yes No

Have you ever been found guilty of tax evasion? Yes No

Have you ever had a professional financial or banking licence revoked? Yes No

Are any criminal or civil proceedings under way or pending against you? Yes No

Have you ever been a member of any terrorist organisation or proscribed political party? Yes No

Will this donation be used to fund terrorism, fraud, drug trafficking or theft? Yes No

Will any of the donations be given to any other charity or individual? Yes No

Will you personally financially benefit from this donation? Yes No

DECLARATION AND SIGNATURE

I declare, under penalty of perjury, that the information given on this form is true to the best of my understanding,
knowledge and belief and that I have read and understood the warnings set out in the preamble to this form.

Signature Date D D M M Y Y Y Y

FOR OFFICIAL USE ONLY

Do not write in this space

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