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Eligibility declaration by a disabled person*

Please note there are penalties for making false declarations

Customer

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 Advice Service on 0845 010 9000 before signing the declaration.

I (full name) ..............................................................................
of (address) ..............................................................................
..................................................................................................
..................................................................................................

declare that:

* I am chronically sick or have a disabling condition by reason of: (please give a full and specific description of your condition)






* and that I am receiving from: Snorestore Ltd, 22 Romney Drive, Harrow, HA2 7EG the following goods
which are being supplied to me for domestic or my personal use:

* DizzyFix device for treatment of BPPV (Benign Paroxysmal Position Vertigo)

and I claim relief from value added tax.

................................................................................ (Signature)
NB typing your name is OK. If you cannot sign yourself, then a parent, guardian or doctor can sign on your behalf.

........................................................................................ (Date)

Supplier

I, Jessica Ruth Gooch, of Snorestore Ltd, 22 Romney Drive, Harrow, HA2 7EG,
am supplying to the person named above the following goods:

DizzyFix device for treatment of BPPV for the personal use of the disabled person.

Jessica Gooch...........................................................................(Signature)

.................................................................................................. (Date)

Please return the completed form to: Snorestore Ltd, 22 Romney Drive, Harrow, HA2 7EG

* Please do not be put off by this term. It is HMRC's wording and does not mean incapacitated.