Form Ftb 4107 - Mandatory E-Pay Election To Discontinue Or Waiver Request Page 2
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2Physician Affidavit of Permanent Physical or Mental Impairment
Patient/Taxpayer – Your physician must complete this affidavit of your permanent physical or mental impairment. Send in
the original affidavit signed by your physician. Keep a copy for your records.
Physician – Complete and sign the following:
Patient Information
Name:
Social Security Number:
Address (number, street, room, or suite number):
City:
State:
ZIP Code:
Physician Affidavit of Permanent Physical or Mental Impairment
Medical License Number:
Physician’s Name:
Physician’s Business Address (number, street, room, or suite number):
City:
State:
ZIP Code:
1. Please provide a description of the patient’s permanent physical or mental impairment. (If you need additional space,
attach a separate piece of paper.)
2. In your medical opinion, does the permanent impairment prevent the patient from using
m
m
a computer?
Yes
No
3. To the best of your knowledge, when did the patient become permanently mentally or physically
/
/
impaired and become unable to use a computer?
____
____
_____
Signature
The patient named above is/was under my care. I completed the above information and declare this statement to be true
and correct to the best of my knowledge and belief under penalty of perjury.
_____________________________________________________________
______________________________
Physician’s Signature
Date
410700121373
FTB 4107 (REV 12-2013) C2 PAGE 3
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