Application For Local Business Tax Account Exemption Form - Disabled War Veteran Page 2
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1
2PHYSICIAN’S CERTIFICATE
STATE OF FLORIDA
COUNTY OF LEE
I, ________________________________________________________________, hereby certify that I am a licensed practicing
(Please print or type)
physician, located at :______________________________________________________________________________ , Florida,
and that I am personally acquainted with ______________________________________________________________________,
(Veteran applicant)
who is applying for a local business tax account to operate a _______________________________________________________
___________________________________________________________________________________________________
_____
(Kind of business)
and who is asking for an exemption from payment of the local business tax receipt as a disabled War Veteran under the
provisions of Section 205.171, Florida Statutes, and that I have this day thoroughly examined the said applicant and found
him/her unable to perform manual labor as a means of livelihood for the following reasons:
______________________________________________________________________________________________
: _______________
Date of exam
Practicing Physician
: _______________________________________________________________
License #: __________________________
CERTIFICATE OF THE LEE COUNTY VETERAN’S SERVICE OFFICE
We, the undersigned officers of the Lee County Veterans Service Office, hereby certify that;
__________________________________________________________, Serial Number: ______________________________
(Please type or print Veteran’s full name)
is an honorable discharged veteran of the United States Armed Forces who was actively assigned to active duty during any war,
declared or undeclared, armed conflicts, crises, etc., who is entitled to the exemption provided under Section 205.171, Florida
Statutes, by reason of disabled from performing manual labor as a means of livelihood for the following reasons:
and that the statements made by him/her in the application of which this certificate is a part are correct.
Duly executed at ___________________________________________________________________________, County of Lee,
State of Florida, under our hands and seals this ________ day of _______________________, A.D. 20___.
(Secretary)_____________________________________ (Chief Officer) ___________________________________________
Title: _____________________________________
Title: ___________________________________________
(Office Seal)
CERTIFICATE OF TAX COLLECTOR
STATE OF FLORIDA
COUNTY OF LEE
I, _______________________________________ Tax Collector of Lee County, hereby certify that no exemption from or on a
local business tax receipt has been granted in this County to__________________________________________________
the person named in the application of which this certificate is a part. In witness hereof I have hereunto set my hand and seal
this _______ day of _______________________, A.D. 20___.
__________________________________________________
Lee County Tax Collector
VeteransExemption
Form#098
Rev. 12/13/06
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