Form Dte 105e - Certificate Of Disability For The Homestead Exemption

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DTE 105E
Rev. 10/07
Certificate of Disability for the Homestead Exemption
Attach this form to the homestead exemption application (form DTE 105A)
if the applicant is requesting the homestead exemption based on disability status.
Ohio Revised Code section 323.151: “ ‘Permanently and totally disabled’ means a person who has, on the first day of January
of the year of application for reduction in real estate taxes, some impairment in body or mind that makes the person unable to
work at any substantially remunerative employment that the person is reasonably able to perform and that will, with reasonable
probability, continue for an indefinite period of at least twelve months without any present indication of recovery therefrom or
has been certified as permanently and totally disabled by a state or federal agency having the function of so classifying
persons.”
To be completed by the applicant
Applicant’s name
Home address
To be completed by the physician, psychologist or state or federal agency representative.
In accordance with the above, I (we) hereby certify that
was, as of Jan. 1,
,
Name of applicant
and is now permanently and totally disabled according to the above definition by virtue of
physical disability or
mental disability.
Ohio license number
Physician (signature)
Print name of person signing form
Psychologist (signature)
Address (please print)
Agency (please print)
City
State
ZIP code
If agency, signature and title of person completing the form
Date
In lieu of having a physician or psychologist licensed to practice in Ohio sign this form, the applicant may submit a statement
from an eligible state or federal agency that the applicant is permanently and totally disabled as defined above. See the back
page of this form for more information on what constitutes acceptable proof of permanent disability.

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