Instructions For Form N-172 - Department Of Taxation State Of Hawaii printable pdf download

INSTRUCTIONS

STATE OF HAWAII — DEPARTMENT OF TAXATION

FORM N-172

INSTRUCTIONS FOR FORM N-172

(REV. 2012)

CLAIM FOR TAX EXEMPTION BY PERSON WITH IMPAIRED SIGHT

OR HEARING OR BY TOTALLY DISABLED PERSON

AND PHYSICIAN’S CERTIFICATION

(NOTE: References to “married”, “unmarried”, and “spouse” also means

“in a civil union”, “not in a civil union”, and “civil union partner”, respectively.)

GENERAL INSTRUCTIONS

Purpose of Form N-172 — Use Part I of Form N-172 to notify the Department of Taxation

that you qualify to claim the special exemptions for persons with impaired sight or hearing or

persons who are totally disabled. Part II of Form N-172 is used to certify blindness, deafness, or

disability for tax purposes. Copies of Form N-172 should be retained by the taxpayer claiming

the exemption and the physician, optometrist, etc., certifying the blindness, deafness, or disability.

For real property tax purposes, contact the Real Property Assessment Division of the county in

which the property is located.

This form should be submitted only once unless Part II, Section A, item 6, Section B, item 5,

or Section C, item 4 indicates that the taxpayer needs to be re-examined. If re-examination is

indicated, a new Form N-172 should be submitted for the year indicated.

Telephone Service for the Hearing Impaired — Telephone service for the hearing impaired

(TDD/TTY) is available through the Oahu Taxpayer Services Branch at 808-587-1418 or toll-free

at 1-800-887-8974.

Applicant’s Social Security Number — The Internal Revenue Service (IRS) issues Individual

Taxpayer Identification Numbers (ITINs) to certain aliens who are required to have a U. S. taxpayer

identification number but who do not have, and are not eligible to obtain, a social security number.

For Hawaii income tax purposes, the ITIN issued by the IRS for these individuals must be used as

the individual’s identification number.

Signatures Required — Form N-172 must be signed by both the taxpayer-claimant (on the

front of the form) and by the certifying physician, optometrist, audiologist etc. (on the back of the

form). Forms that are not signed are incomplete and will not be processed.

DEFINITIONS

‘Blind’ means a person whose central visual acuity does not exceed 20/200 in the better eye

with correcting lenses, or whose visual acuity is greater than 20/200 but is accompanied by a

limitation in the field of vision such that the widest diameter of the visual field subtends an angle

no greater than twenty degrees.

* * *

‘Deaf’ means a person whose average loss in the speech frequencies (500-2000 Hertz) in the

better ear is eighty-two decibels, A.S.A., or worse.

* * *

PLEASE NOTE:

For purposes of impairment certification, a qualified ophthalmologist, optometrist, or

otolaryngologist may be licensed to practice in any state or a commissioned medical officer

in the armed forces. Hearing impairment may be certified by an audiologist licensed under

chapter 468E, Hawaii Revised Statutes (HRS).

* * *

‘Person totally disabled’ means a person who is totally and permanently disabled, either

physically or mentally, which results in the person’s inability to engage in any substantial gainful

Instructions For Form N-172 - Department Of Taxation State Of Hawaii

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