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Customer Declaration  
If you are in any doubt as to whether you are eligible to receive goods or services zero-rated for VAT you should consult Notice 701/7 VAT reliefs for disabled people or contact our National Advise Service on 0845 010 9000 before signing the declaration.
I (Full Name)
..
Address ( as above)
Declare that:
- I am chronically sick or have a disabling condition by reason of : (give full and specific description of your condition);
-
and that
- I am receiving from East Anglian Mobility Warehouse.
- the following goods which are being supplied to me for domestic or my personal use:
(description of goods)
- the following services to adapt goods to suit my condition:
(description of services and goods)
- the following services of installation, repair or maintenance of goods:
(description of services and goods)
- the following alterations to my private residence:
(description of alteration)
- the services of monitoring a personal alarm call system.
And I claim relief from value added tax
(signature)
(date)
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