Fillable Schedule Dis - Kansas Certificate Of Disability

2013

KANSAS

DIS

CERTIFICATE OF DISABILITY

(Rev. 8/13)

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 2013. 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 2013 must not exceed the limits set by the Social Security Administration for 2013: $12,480 if the impairment

is other than blindness; $20,880 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 2013?

‰

YES

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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Schedule Dis - Kansas Certificate Of Disability - 2013