Schedule Dis - Kansas Certificate Of Disability - 2011
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12011
KANSAS
DIS
CERTIFICATE OF DISABILITY
(Rev. 8/11)
If you are claiming homestead benefits because of disability, this form must be completed by a duly licensed physician
and enclosed with your Homestead Claim, Form K-40H. Instead of this schedule, you may enclose a copy of your Social
Security certification of disability letter that shows you are receiving benefits based upon a total and permanent disability
which prevented you from being engaged in any substantial gainful activity during the entire calendar year of 2011. You may
enclose a copy of your original Veterans Disability Statement or request a letter from your regional Veterans Administration
that includes your disability date and percentage of permanent disability. Annual income derived from any substantial gainful
activity during 2011 must not exceed the limits set by the Social Security Administration for 2011: $12,000, if the impairment
is other than blindness; $19,680 if the individual is blind.
NAME OF PERSON EXAMINED _____________________________________________________________________
SOCIAL SECURITY NUMBER _______________________________________________________________________
ADDRESS _______________________________________________________________________________________
Street or RR (Include apartment number or lot number)
_______________________________________________________________________________________________
City
State
Zip Code
1. Does the individual qualify as having a disability preventing them from engaging in any substantial gainful activity by
reason of any medically determinable physical or mental impairment which can be expected to result in death and/or has
lasted for the entire year of 2011?
‰
‰
YES
NO
2. Nature of disability. ____________________________________________________________________________
___________________________________________________________________________________________
3. When was the condition originally diagnosed? ______________________________________________________
CERTIFICATION OF PHYSICIAN
I, _________________________________________________ , certify that I have personally examined the physical and
mental condition of the above named individual.
SIGNATURE OF PHYSICIAN _______________________________________________________________________
PHYSICIAN’S NAME _____________________________________________________________________________
Please type or print
BUSINESS ADDRESS ____________________________________________________________________________
Street or RR
______________________________________________________________________________________________
City
State
Zip Code
(
)
PHONE ______________________________________
DATE _______________________________
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