Form N-857 - Physician'S Or Optometrist'S Certified Report On Eye Or Hearing Examination Or Disability For Tax Exemption Purposes

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FORM
STATE OF HAWAII — DEPARTMENT OF TAXATION
File with Form N-172
Physician’s or Optometrist’s Certified Report on Eye or
N-857
Hearing Examination or Disability for Tax Exemption Purposes
(REV. 2000)
(Complete only one part, even if applicant has multiple disabilities.
This form may be rejected if the appropriate part and the certification are not fully completed.
If Part I is completed, sign authorization for release of information on reverse side.)
Applicant’s Name ___________________________________________________________
Social Security No. ______________________________
Spouse’s Name _____________________________________________________________
Spouse’s S.S.N. _________________________________
Address _____________________________________________________________________
Hawaii G.E./Use I.D. No. _________________________
PART I — EYE EXAMINATION
(Must be done by a qualified ophthalmologist or optometrist.)
a. Diagnosis ____________________________________________________________________________
b. Vision 1) without corrective lenses:
OD: ________ OS: ________
2) with corrective lenses:
OD: ________ OS: ________
c.
Is this applicant’s visual acuity 20/200 or worse in the better eye with corrective lenses:
Yes
No
d. Is the widest diameter of the field of vision less than 20 degrees?
Yes
No
e.
Date first certifiable as legally “blind” __________________________________________________
f.
Should applicant be re-examined for tax purposes?
Yes
No
If “Yes”, when? ____________________________
(Must be done by a qualified otolaryngologist; i.e., Board-certified ear,
PART II — HEARING EXAMINATION
nose, & throat specialist.)
a. Diagnosis ________________________________________________________________________________________________________________
b.
Hearing loss (500-2000 Hertz) without aid:
Right________________
Left _________________ (Decibels ASA or ANSI 1969)
c.
Is the applicant’s average loss in speech frequencies (500-2000 Hertz) in the better ear, 82 Decibels ASA
(or 92 Decibels ANSI 1969) or worse?
Yes
No
d. Date first certifiable as legally “deaf” __________________________________________________
e.
Should applicant be re-examined for tax purposes?
Yes
No
If “Yes”, when? ____________________________
(Must be done by physicians as described in the definition for “person totally
PART III — REPORT ON DISABILITY
disabled” under section 235-1, Hawaii Revised Statutes.)
a. Diagnosis ________________________________________________________________________________________________________________
b. Date individual became under your care?___________________ Date individual first disabled or unable to work? _________________
c.
Is the individual totally disabled, either physically or mentally?
Yes
No
d.
Is the disability permanent? (See "Person totally disabled" under Definitions on reverse side.)
Yes
What is the effective date of disability? ______________________________________
No
When should individual be re-examined to determine extent of disability? _________________________
e.
Is the individual able to engage in any substantial gainful business or occupation? (See "Person totally disabled" under Definitions
on reverse side.)
Yes
No
f.
Pertinent symptoms or findings that preclude the individual’s ability to engage in gainful work.
_________________________________________________________________________________________________________________________
CERTIFICATION BY PHYSICIAN, OPTOMETRIST, ETC.
I hereby certify that the above applicant conforms to the State definition of “Blind”, “Deaf”, or “Totally Disabled”. Sign this
certification only if the applicant meets the applicable definition.
Date of certification
Signature of Qualified Person As Described Above
License Number
Date License Expires
Print name of Qualified Person As Described Above
State/Other Licensing Authority
Address of Qualified Person As Described Above
FORM N-857

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