Read the declaration statement.

If the claim is for your NHS wig or fabric support costs, sign your name in Part 4A. Write the date when you signed the form.

If you are filling in this form for someone who is physically incapable of doing so, they should sign or make their mark in Part 4A.

If you are filling in the form for someone with learning difficulties or a condition that prevents them from managing their own affairs, you should sign your name in Part 4B. Write your name, address and telephone number.