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: Numark Pharmacy, 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: ___________________________________________
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.
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 purpose of obtaining VAT relief.