Form Dr-416 - Physician'S Certification Of Total And Permanent Disability printable pdf download

Form Dr-416 - Physician'S Certification Of Total And Permanent Disability

PHYSICIAN’S CERTIFICATION OF

DR-416

R. 11/12

TOTAL AND PERMANENT DISABILITY

Rule 12D-16.002

Florida Administrative Code

Effective 11/12

, a physician licensed pursuant to Chapter 458 or Chapter 459,

Physician’s name

Florida Statutes, hereby certify that

Mr.

Mrs.

Miss

Ms.

Name of totally and permanently disabled person

Social Security Number*

, is totally and permanently disabled as of January 1,

due to the following mental or physical condition(s):

Quadriplegia

Paraplegia

Hemiplegia

Legal blindness

Other total and permanent disability requiring use of a wheelchair for mobility

Check here if patient is totally or permanently disabled but does not require a wheelchair for mobility.

It is my professional belief the above condition(s) render

Mr.

Mrs.

Miss

Ms.

totally and permanently disabled and the foregoing statements

are true, correct, and complete to the best of my knowledge and professional belief.

Signature

Date

Address:

(print)

Street

City

State

Zip

Florida Board of Florida Board of Medicine or Osteopathic Medicine license number

Issued on

NOTICE TO TAXPAYER: Each Florida resident applying for a total and permanent disability

exemption must present to the county property appraiser, on or before March 1 of each year, a copy

of this form or a letter from the United States Department of Veterans Affairs or its predecessor. Each

form is to be completed by a licensed Florida physician.

NOTICE TO TAXPAYER AND PHYSICIAN: Section 196.131(2), Florida Statutes, provides that any

person who knowingly and willfully gives false information for the purpose of claiming homestead

exemption commits a misdemeanor of the first degree, punishable by a term of imprisonment not

exceeding 1 year or a fine not exceeding $5,000, or both.

*Disclosure of your social security number is mandatory. It is required by sections 196.011(1) and 196.101(5),

Florida Statutes. The social security number will be used to verify taxpayer identity information and homestead

exemption information submitted to property appraisers.

Form Dr-416 - Physician'S Certification Of Total And Permanent Disability

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