of address as above declare that I am chronically sick or disabled by reason of: (give a full and specific description of your condition below)

and that I am receiving from INDEPENDENT LIVING COMPANY (INDEPENDENT LIVING MOBILITY LIMITED) 11 Hale Lane Mill Hill London NW7 3NU the following goods which are being supplied to me for domestic or my personal use (description of goods see below), and I claim relief from VAT under Group 14 of Schedule 5 to the Value Added Tax Act 1983.

If you are buying the goods on behalf of a chronically sick or disabled person please give your name or charity's name.

Note: 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.