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Charges or has had optical charges paid for them. Part 4 tells you where to send the completed form. Before you do this, you must sign and date the declaration. WHAT CAN YOU CLAIM FOR? NOTE The information on this form may be disclosed in confidence to other public bodies as appropriate for the purposes of checking entitlement and preventing or detecting fraud. False information may lead to prosecution or legal action. Use this form to claim back the cost of a sight test, glasses or contact.

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