VAT Exemption Form

Goods and Services for Disabled Persons: Eligibility Declaration by an Individual

I (full name) ___________________________________________________

Of (address) ______________________________________________________________________________________________________________

Declaration that I am chronically sick or disabled by reason of: ________________________________________________________________________

(give full and specific description of your condition)

________________________________________________________________________

and that I am receiving from: Vantage Pharmacy,14-20 Field St Shepshed,Leics,LE12 9AL ________________________________________________________________________

the following goods which are being supplied to me for domestic or my personal use: ____________________________________________________

(enter description of goods)

________________________________________________________________________

and I claim relief from value added tax under Group 14 of Schedule 5 to the Value Added Tax Act 1983.

Signature: ________________________________________

Date: ___________________________________________

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 be false for the purposes of obtaining VAT relief.

Note to Supplier

You must keep this declaration for production to your VAT office. The production of this Certificate does not automatically authorise the zero-rating of the supply. You must also ensure that the goods and services you are supplying qualify for zero-rating.

Note to 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 your local VAT office before signing the declaration.