Schedule H - Homeowner And Renter Property Tax Credit 2006 (Page 3 of 3) in pdf

Schedule H - Homeowner And Renter Property Tax Credit 2006 Page 3

*069980130000*

2006 sCheDULe h Page 3

Last name and SSN

Physician’s certification of blindness or disability

If you are blind or disabled, you must have this certificate completed each

time you claim the Property Tax Credit and submit it with your Schedule H.

Claimant’s first name

m.I.

Last name

Claimant’s social security number

I certify that the above-named claimant

(fill in all that apply):

is blind

has a physical or mental impairment that is expected to last continuously for 12 months or more

was physically or mentally impaired on January 1, 2006

Physician’s first name

m.I.

Last name

Physician’s address (number and street)

suite number

City

state

Zip Code +4

Physician’s signature

Date

Where Licensed

License No.

Definitions

Blind

Vision that does not exceed 20/200 in the better eye with

correcting lenses, or vision that is greater than 20/200, but is

accompanied by a limitation in the field of vision such that

the widest diameter of the visual field subtends an angle no

greater than 20 degrees.

Disabled

Unable to engage in any gainful activity due to a physical or

mental impairment which can be expected to last for 12

months or more.

2006 sCheDULe h P3

homeowner and renter Property tax Credit

File order 7

revised 10/06

Schedule H - Homeowner And Renter Property Tax Credit 2006 Page 3