Form 150-101-057 - Disability Certification - 2013

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DISABILITY CERTIFICATION
Instructions for Disability Income Tax Credit
3. Claim the $50 credit on your Oregon income tax return as an
“other credit.” Identify the credit by writing the numeric code
1. You must have suffered a permanent and complete loss of
717 and $50, the credit amount, in the boxes provided.
function of two limbs on or before the close of the tax year
for which the credit is claimed.
4. You only need to obtain the certification once. Be sure to keep
this form with your permanent records. Upon request, the form
2. This certificate must be completed by your county health
shall be provided to the department to verify the credit.
officer.
I, _________________________________________________________________________________________ , the appointed public
health officer of ____________________________________________________________________________ county have examined
____________________________________________________________________________________________________________
Applicant’s Last Name
First Name
Middle Initial
Social Security Number
for the purposes of the Oregon income tax credit for certain disabilities. After examination, I find that the applicant has
suffered PERMANENT and COMPLETE loss of function of:
Both Arms
Both Legs
One Arm and One Leg
Date of Disability ______________________________
Signature ______________________________________________________
Date ____________________________
150-101-057 (Rev. 12-13)

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