Standing Order Instruction

To _____________________________ Bank/Building Society

_____________________________ Branch

Please pay the sum of £ _____ to the Bemerton PCC

account at Lloyds TSB Bank plc, Salisbury Branch, Sorting Code 30-97-41,

Account Number 01380004 monthly on _______________ (date) until further

notice.

Please debit my account at:

Bank ___________________________________________

Branch ___________________________________________

Sorting Code–

Account Number  ________________________

Signature _________________________ Date _____________