Form Dis - Kansas Certificate Of Disability 1999 (Page 2 of 2) in pdf

Form Dis - Kansas Certificate Of Disability 1999 Page 2

Use this form if the claimant is incapable of signing the Homestead Claim.

If a guardian or conservator has been appointed, a power of attorney executed,

or other legal action taken, a copy of the appointing documentation must be

submitted.

SUPPORT OF DEMAND FOR HOMESTEAD REFUND

I, the undersigned, of lawful age, depose that I am well acquainted with the

facts concerning the Homestead Claim for the year ______________ of the

claimant ____________________________________________________,

Social Security no. ___________________, that a homestead refund is rightfully

due, and that the marked set of circumstances describe the situation of the

claimant:

The claimant is incompetent, there has been no judicial appointment of a

guardian or conservator, and the individual is a spouse or adult child of the

incompetent and should rightfully receive the homestead refund.

The claimant is blind, ill, or incapable of signing the Homestead Claim.

Other reason. (Be specific):

That if the: State of Kansas; Secretary of Revenue; Director of Accounts and

Reports; State Treasurer; or any of their officers, agents or employees, certify,

prepare, sign or deliver to myself the Kansas homestead refund and any demand

or claim is made upon the: State of Kansas; Secretary of Revenue; Director of

Accounts and Reports; State Treasurer; or their officers, agents or employees by

any person whatsoever, I shall at all times save the: State of Kansas; Secretary

of Revenue; Director of Accounts and Reports; State Treasurer; or their officers,

agents and employees, harmless, free and clear of all costs, expenses or damages

occasioned by the certification, preparation, signing, or delivery of the homestead

refund of

, to me.

Name of Claimant

Under the penalties of perjury, I declare that the information I have furnished

above, to the best of my knowledge, is true, correct, and complete.

Date

Name (Print or Type)

Signature

Address

City, State, and Zip Code

HS-9

(Rev. 9/99)

Form Dis - Kansas Certificate Of Disability 1999 Page 2