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
Doctor’s Signature
* 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


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