Form Ftb 2194-4 - Affidavit Of Doctor For Homeowner And Renter Assistance Program printable pdf download

Form Ftb 2194-4 - Affidavit Of Doctor For Homeowner And Renter Assistance Program

Affidavit of Doctor for Homeowner and Renter Assistance Program

Patient/Claimant: Fill in your name and social security number below, then ask your doctor to

complete this affidavit of disability. Attach the affidavit when you file your claim.

Patient’s/Claimant’s name: ________________________________________________________

Patient’s/Claimant’s social security number: __________________________________________

Doctor complete the following:

Doctor’s name: _________________________________________________________________

Doctor’s business address: _______________________________________________________

Doctor’s business telephone: (______) _____________________

California medical license number: _________________________________________________

The patient named above was under my care, and I completed the above information. In my

professional opinion, on December 31, 2003, the patient was disabled to such extent that he/she was

incapable of engaging in any substantial gainful activity (previous work or other work). I further declare

that this patient’s disability lasted or was expected to last for at least 12 consecutive months, including

December 31, 2003.

I declare this statement to be true and correct to the best of my knowledge and belief under penalty of

perjury:

______________________________________

_____________________________

Doctor’s Signature

Date

* For example, for purposes of homeowner and renter assistance, the 12-month consecutive period of

disability can occur at any time between January 1, 2003 through December 30, 2004, so long as it

includes December 31, 2003.

HRA 2004 Claim Year

FTB 2194-4 Page 11

Form Ftb 2194-4 - Affidavit Of Doctor For Homeowner And Renter Assistance Program