I (full name) :                                                               

Of (address) :

Declare that;

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

·                  I am receiving from First Choice Mobility, 19 Tanning court, Warrington;

·                  The following goods which are being supplied to me for domestic or my personal use: (description of goods)

And I claim relief from value added tax.

Signature:

Date: