XR UK Arrestee and Legal Support Expenses Claim Form
April 2022 Rebellion
Name (as is on bank account)
*
First Name
Last Name
Please fill in the table below with the date and amount of the expense and what you spent money on:
*
Total Cost:
*
This should match up to the total of all values in column 3 of the above table
Please upload images of all receipts:
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of
Email Address:
*
example@example.com
Phone Number:
-
+44
Phone Number
Account Number:
*
8 digits
Sort Code:
*
6 digits
Any other details:
Please double check all the the details, specifically sort code and account number, before you submit!
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Should be Empty: