Application For Partial Exemption From Real Estate Taxation For Property Of Physically Disabled Crime Victims 2003 Page 4

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Application for Partial Exemption from Real Estate Taxation for Property of Physically Disabled Crime Victims
Page 4
SECTION 3 - PHYSICIAN REPOR T
If the disabled person is legally blind and that is the only reason for applying for exemption, a copy
of a certificate from the State Commission for the Blind and Visually Handicapped may be attached in
lieu of completing this section. Otherwise this section must be completed by a licensed physician.
1.
Physician’s name: ________________________________________________________________________
2.
New York State License Number: ____________________________
Date of Issue: _________________
3.
Office Address: __________________________________________________________________________
_______________________________________________________________________________________
4.
Patient’s Name: __________________________________________________________________________
5.
Patient’s Address: ________________________________________________________________________
_______________________________________________________________________________________
6a. Does patient have a physical impairment which substantially limits one or
more major life activities?..........................................................................................
YES
NO
6b. IF YES, give description of patient’s physical disability: ___________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
7.
Explain how improvements to real property facilitates and accommodates the patient’s use and accessibility
of the property: __________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
CERTIFICATION AND SIGNATURE
I certify that all statements made in this section are true and correct to the best of my belief.
_______________________________________________________________
____________________________
Signature of Physician
Date
Disabled Crime Victim Exemption Application 10/04

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