Form Dte 105e - Certificate Of Disability For The Homestead Exemption
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DTE 105E
Rev. 7/13
Certifi cate of Disability for the Homestead Exemption
Attach this form to the homestead exemption application (form DTE 105A)
if the applicant is requesting the homestead exemption based on disability status.
Ohio Revised Code section 323.151: “ ‘Permanently and totally disabled’ means a person who has, on the fi rst day of Janu-
ary of the year of application for reduction in real estate taxes, some impairment in body or mind that makes the person un-
able to work at any substantially remunerative employment that the person is reasonably able to perform and that will, with
reasonable probability, continue for an indefi nite period of at least twelve months without any present indication of recovery
therefrom or has been certifi ed as permanently and totally disabled by a state or federal agency having the function of so
classifying persons.”
To be completed by the applicant
Applicant’s name
Home address
To be completed by the physician, psychologist or state or federal agency representative.
In accordance with the above, I (we) hereby certify that
was, as of Jan. 1,
,
Name of applicant
and is now permanently and totally disabled according to the above defi nition by virtue of
physical disability or
mental disability.
License number and state issuing (Note: If reason for reduction is
mental disability, the physician or psychologist must hold an Ohio license.)
Physician (signature)
Print name of person signing form
Psychologist (signature)
Address (please print)
Agency (please print)
City
State
ZIP code
If agency, signature and title of person completing the form
Date
In lieu of having a physician or psychologist sign this form, the applicant may submit a statement from an eligible state or
federal agency that the applicant is permanently and totally disabled as defi ned above. See the back page of this form for
more information on what constitutes acceptable proof of permanent disability.
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