Form 24746 - Physician'S Certificate

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Physician's Certificate
I hereby certify that __________________________________ of _______________________________________,
Mailing Address
Applicant
____________________________, of __________________________ County is permanently and totally disabled.
City
For the purposes of this certifi cate, "'Permanently and totally disabled' means the inability to engage in any substantial
gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result
in death or has lasted or can be expected to last for a continuous period of not less than twelve months as established
by a certifi cate from a licensed physician."
(North Dakota Century Code § 57-02-08.1(5)(e))
__________________________________________
__________________________________________
Name of Physician (please print)
Address
__________________________________________
__________________________________________
Signature of Physician
Date
This certifi cate is required for applicants who are less than 65 years of age and who claim the permanently and
totally disabled person's property tax credit or renter's refund pursuant to North Dakota Century Code § 57-02-08.1.
24746 (Rev. 11/2005)
57-02-08.1. Homestead credit. (Quoted in part):
1. a.
Any person sixty-fi ve years of age or older or permanently and totally disabled, in the year in which
the tax was levied, with an income that does not exceed the limitations of subdivision c is entitled to
receive a reduction in the assessment on the taxable valuation on the person's homestead. An exemption
under this subsection applies regardless of whether the person is the head of a family.
2. a.
Any person who would qualify for an exemption under subdivisions a and c of subsection 1 except for
the fact that the person rents living quarters is eligible for refund of a portion of the person's annual
rent deemed by this subsection to constitute the payment of property tax.
5. e.
"Permanently and totally disabled" means the inability to engage in any substantial gainful activity
by reason of any medically determinable physical or mental impairment which can be expected to
result in death or has lasted or can be expected to last for a continuous period of not less than twelve
months as established by a certifi cate from a licensed physician.

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