10.1 Eligibility declaration by a disabled
person
If you are in any doubt as to whether you are eligible to receive goods or services at 
Zero-rated VAT you should consult Notice 701/7 VAT relief’s for disabled people or
Contact our National Advice Service on 0845 010 9000 before signing the declaration.

I (Full Name) .............................................................................. 
(Address) ..............................................................................
..................................................................................................
Your Internet Order Number ....................................................
Declare that:
??I am chronically sick or have a disabling condition by reason of:
(Give full and specific description of your condition); and that
??I am receiving from: (name and address of supplier)
* The following goods which are being supplied to me for
Domestic or my personal use:
(Description of goods on a separate sheet)
* The following services to adapt goods to suit my condition:
(Description of services and goods)
* The following services of installation, repair or
Maintenance of goods:
(Description of services and goods)
* The following alterations to my private residence:
(Description of alteration)

................................................................................ (Signature)
........................................................................................ (Date)

Notice 701/7 VAT Relief’s for disabled people 

Supplier

Plumbing and Heating Store Ltd
1 Trinity Street
Ipswich
Suffolk
IP3 0AB

Is supplying to the person named above?
The following goods:
Description of services and goods on separate sheet)

................................................................................ (Signature)
........................................................................................ (Date)