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J. Stott and Sons Ltd
Unit C3
Cunliffe Road
Whitebirk Industrial Estate
Blackburn BB1 5SU

01254 588733 (fax 01254 690741)

VAT Registration Number 174 605 656

Please note there are severe penalties for making false declarations

If in doubt, then more information can be obtained from the Customs & Excise Notice 701/7 ‘VAT relief's for disabled people’ or contact the Customs and Excise National Advice Service on 0845 010 9000 before signing this declaration.

 (full name) …………………………………………………………………………………………………….

(address) ……………………..…………………………………………………………………………….........

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Post Code………………………………

Telephone No………………….…………………………….

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

……………………………………………………………………….……………………………….

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and that I am receiving from J. Stott and Sons Ltd (Rechargeonline) the following goods which are being supplied to me for domestic or my personal use: And I claim relief from value added tax.

(description of goods)…………………………………………….…………………………………

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……..………………….…………………………………………………………………………….(Signature)

…………………….………………………………………………………………………………………(Date)