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Email Address:
I FULL NAME OF PERSON CLAIMING VAT RELIEF
OF: (ADDRESS)
DECLARE THAT: I AM CHRONICALLY SICK OR HAVE A DISABLING CONDITION BY REASON OF.(MUST STATE)
I / WE CLAIM RELIEF FROM VALUE ADDED TAX PLEASE ENTER YOU FULL NAME (THIS IS YOUR ELECTRONIC SIGNATURE)
FOR AN ELIGIBLE CHRONICALLY SICK OR DISABLED PERSON OR FOR MY DOMESTIC OR PERSONAL USE.
OR: THE GOODS WILL BE MADE AVAILABLE THROUGH THE ABOVE CHARITY TO A DISABLED PERSON OR PERSONS FOR THE DOMESTIC OR THERE PERSONAL USE.
TODAYS DATE
YOUR EMAIL ADDRESS:
TELEPHONE NUMBER:
PRODUCT OR SERVICE PURCHASED:
PURCHASE TOTAL


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