EXCHANGE FORM

BANKNOTES (A) To exchange your foreign currency and coins, fill out this exchange form and send it, along with your banknotes and coins to our address: Currency Name amount L.O.C. - 3rd Floor - 207 Regent Street - London W1B 3HH - United Kingdom American Dollar USD Fill in part A to exchange banknotes and part C for coins. Write down the amount per currency Australian Dollar AUD submitted for exchange. Fill in your personal details, and preferred payment currency and method Austrian Schilling ATS in part B and sign and date the declaration in part D. When the exchange form is filled out completely and signed, send it along with your banknotes and coins to our address. Upon receipt Belgian Franc BFR of your consignment, we will send you a confirmation email and a link to our feedback form. A few Brunei Dollar BND working days later you will receive the exchange value for your submitted notes and coins. Canadian Dollar CAD Croatian Kuna HRK Cypriot Pound CYP PAYMENT DETAILS AND PREFERENCES (B) Czech Koruna CZK Danish Krone DKK first name + name Changing Lives Deutsche Mark DEM house number street + Unit D13 Marquis Court, Tenth Avenue West Dutch Guilder NLG postcode + city Egyptian Pound EGP NE11 0RU Gateshead Estonian Kroon EEK county/state/province Tyne and Wear Euro EUR country United Kingdom Finnish Markkaa FIM e-mail address * French Franc FRF ( ) Greek Drachma GRD IBAN code (**) Hong Kong Dollar HKD (or sort code Hungarian Forint HUF 20-59-97 + account number) Indian Rupee INR 90892084 Irish Pound IEP account holder ** ( ) Changing Lives Israeli Shekel ILS preferred payment method Paypal Cheque Italian Lira ITL Japanese Yen JPY x Bank Transfer x Charity (***) Luxembourgish Franc LUF preferred payout currency Pounds Euros Maltese Lira MTL US Dollars Moroccan Dirham MAD New Zealand Dollar NZD (*) e-mail address to which we will send the confirmation email. If you choose Paypal as your preferred payment method we will send the payment to this email address Norwegian Krone NOK , . (**) Only applies if you choose for bank transfer as your preferred payment method. Fill in Oyster Cards TfL account holder's full name and either the IBAN account number or the sort code (or BIC Philippine Peso PHP code) and the account number. (***) If you select this box, we will donate the exchange value to charity. You do not have Polish Zloty PLN to provide any payment details. More information on LeftoverCurrency.com/charity Portuguese Escudo PTE Pound Sterling GBP (C) England £ COINS Channel Islands £ American Dollar USD Japanese Yen JPY Gibraltar £ Austrian Schilling ATS Norwegian Krone NOK Isle of Man £ Canadian Dollar CAD Polish Zloty PLN Northern Ireland £ Croatian Kuna HRK Pound Sterling GBP Scotland £ Czech Koruna CZK Slovak Koruna SKK Romanian Old Lei ROL Danish Krone DKK Slovenian Tolar SIT Romanian Lei (polymer) RON Deutsche Mark DEM Spanish Peseta ESP Saudi Riyals SAR Euro EUR Swedish Krona SEK Singapore Dollar SGD Hungarian Forint HUF Swiss Franc CHF Slovak Koruna SKK Irish Pound IEP Thai Baht THB Slovenian Tolar SIT Spanish Peseta ESP Swedish Krona SEK I declare that I have obtained all submitted banknotes and coins DECLARATION (D) in a lawful manner, and not by any criminal act. I confirm to be Swiss Franc CHF entitled to ofer these banknotes, cards and coins for exchange, under the conditions stated in our Terms and Thai Baht THB Conditions, which can be found at http://www.LeftoverCurrency.com/terms-and-conditions. I have read these Turkish Old Lira TRL terms and conditions, I understand them and agree with them. I hereby declare that all the information provided in this form is true to the best of my knowledge and belief. Turkish Lira TRY UAE Dirham AED date:

signature: