Physician'S Statement Verifying Eligibility For Disability Homestead Exemption printable pdf download

Physician'S Statement Verifying Eligibility For Disability Homestead Exemption

Harris County Appraisal District

Physician's Statement Verifying Eligibility

Exemption Center

P. O. Box 922012

for Disability Homestead Exemption

Houston, Texas 77292-2012

(713) 957-7800

Tax Year:

Account Number:

Form GTA:IAD:013 04/09

INSTRUCTIONS: Complete Part A of this form and have your physician

complete Part B. YOUR PHYSICIAN MUST MAIL THIS COMPLETED

FORM to the Exemption Center at the address shown above.

Part A (to be completed by the Property Owner)

Name of Property Owner Claiming Exemption

Property Address or Legal Description

Year(s) to which this form applies

Part B (to be completed by Physician)

Verification of Disability

My name is

, and I am a physician currently licensed to

practice in Texas.

I am personally knowledgeable of the type and extent of physical or mental impairment that currently affects

and have treated or examined this person's condition.

This impairment is one that results from anatomical, physiological, or psychological abnormalities, which are

demonstrable by medically acceptable clinical and laboratory diagnostic techniques. My diagnosis of the impairment

can be described as follows:

Check one:

This impairment prevents the person named above from engaging in any substantial, gainful activity and has lasted or

is expected to last at least 12 months or result in death.

This person is 55 years of age or older, is legally blind, and is unable to engage in his/her previous occupation

because of the blindness.

This impairment occurred on or before

Physician's Signature

Printed Name

Date

Office Address

Telephone Number (area code and number)

Physician's Office: Please mail this form to the Harris County Appraisal District's Exemption Center, P.O. Box 922012, Houston, TX 77292-2012.

Additional information about the Disability Homestead Exemption is on the back of this form

Physician'S Statement Verifying Eligibility For Disability Homestead Exemption