I (full name)

of (address)

declare that

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

• The adapted vehicle is for my personal use

• I usually use a wheelchair or stretcher to be mobile.

and I claim relief from value added tax

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

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

Supplier

I (full name)

of (address)

am supplying the following goods and services to the person named above

• the following motor vehicle which is being supplied for domestic or personal use (description of vehicle and details of adaptation) or

• the following services to adapt a motor vehicle to suit his/her condition: (description of services and motor vehicle) or

• the following services of installation, repair or maintenance of motor vehicle: (description of services and goods) or

• the services of leasing a motor vehicle for the personal use of the disabled person.

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

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

• delete words not applicable

Note

You should keep this declaration for production to your VAT officer. The production of this declaration does not automatically justify the zero-rating of the supply. You must ensure that the motor vehicle and services you are supplying qualify for zero-rating.