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Your Bank
Bank Address
.Post Code
Sort Code: Account no:
Your Name
Please pay the sum of: .. per month to the account of Keep Hackney NHS
Public, Unity Trust Bank, Nine Brindley Place, Birmingham B1 2HB
Sort Code: 08 60 01 Account number: 20179157
Starting on (insert date) .. and please continue to make this payment until
notified by me in writing.
Signed Date: