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CHARITY
RECIPIENT
DECLARATION
H.M. FOREIGN
OFFICE
FO-CY266-B
Revision 3 (01/08)
CHARITY
RECIPIENT
DECLARATION
H.M. FOREIGN
OFFICE
CHARITY
RECIPIENT
DECLARATION
H.M. TREASURY
CHARITY
RECIPIENT
DECLARATION
H.M. FOREIGN OFFICE
Your Name
Your Address
Telephone Number
+
E-Mail Address
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
INV367-E
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
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.
CHARITY
RECIPIENT
DECLARATION
H.M. FOREIGN OFFICE
Address
Postcode/Zipcode Country
Telephone Number
+
E-Mail Address
Does this charity seek to carry out religious conversion or indoctrination? 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
Please give full details of what the purpose and primary objective of the charity is (use a separate sheet if
necessary)
Please explain IN DETAIL what you will use the charitable donation you will be receiving for (Use a
separate sheet if necessary)
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
Please give full details of bank accounts, WU collection agencies, etc to be used
If you have answered “NO” above, please indicate why taxes will not been paid
CHARITY
RECIPIENT
DECLARATION
H.M. FOREIGN OFFICE
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 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
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