VAT Exemption Form for the
Disabled

Goods and Service for Disabled Persons: Eligibility Declaration by an individual.

I declare that I am chronically sick and disabled. (Please give a full and specific description of your condition)

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-------------------------------------- And that I am receiving from Mobility Choice the following goods which are being
supplied to me for domestic or personal use (Description of goods - please enter on the reverse of this form),
and claim relief from value added tax under Group 14 of Schedule 5 to the Value Added Tax Act 1983

Signature....................................................................

Print name..........................................................................................

Address:....................................................................................................

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Post Code...................... Telephone No...................................................

Note to customer: If you are in doubt as to whether you are eligible to receive goods or services zero-rated for VAT,
you should consult your local VAT office before signing this declaration.

WARNING: Section 39.2 of the VAT Act 1983 provides for severe penalties for anyone who makes use of
a document which they know to the false for the purposes of obtaining VAT relief.

Please print off, sign and return to: Colin Matthews, 10 Bro Teifi, Cardigan SA43 1DS

VAT Exemption Form for the Disabled

VAT Exemption Form for the
Disabled