Form N-172 - Claim For Tax Exemption By Person With Impaired Sight Or Hearing Or By Totally Disabled Person And Physician'S Certification Page 2

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FORM N-172

(REV. 2012)

PAGE 2

Social Security Number _________________________

Applicant’s Name ___________________________________

Part II

Physician’s or optometrist’s certification. Complete only one section, even if applicant has multiple disabilities.

This form may be rejected if the appropriate section and the certification are not fully completed. If

Section A is completed, sign authorization for release of information located at the bottom of this page.

SECTION A — EYE EXAMINATION

(Must be done by a qualified ophthalmologist or optometrist.)

Diagnosis _____________________________________________________________________

Vision 1) without corrective lenses:

OD: _______

OS: _______

2) with corrective lenses:

OD: _______

OS: ______



Is this applicant’s visual acuity 20/200 or worse in the better eye with corrective lenses?

Yes



Is the widest diameter of the field of vision less than 20 degrees?

Yes

Date first certifiable as legally “blind” (MM/DD/YYYY) ___________________________________



Should applicant be re-examined for tax purposes?

Yes

If “Yes”, when? ____________________

(Must be done by a qualified otolaryngologist; i.e., Board-certified ear,

SECTION B — HEARING EXAMINATION

nose & throat specialist, or a licensed audiologist.)

Diagnosis ________________________________________________________________________________________

Hearing loss (500-2000 Hertz) without aid:

Right ______________

Left _______________ (Decibels ASA or ANSI 1969)

Is the applicant’s average loss in speech frequencies (500-2000 Hertz) in the better ear, 82 Decibels ASA



(or 92 Decibels ANSI 1969) or worse?

Yes

Date first certifiable as legally “deaf”(MM/DD/YYYY) ____________________________________



Should applicant be re-examined for tax purposes?

Yes

If “Yes”, when? ____________________

(Must be done by physicians as described in the definition for “person

SECTION C — REPORT ON DISABILITY

totally disabled” under section 235-1, Hawaii Revised Statutes.)

Diagnosis ________________________________________________________________________________________

Date individual came under your care ____________ Date individual first disabled or unable to work _______________



Is the individual totally disabled, either physically or mentally?

Yes

Is the disability permanent? (See “Person totally disabled” under Definitions in separate instructions.)



Yes

What is the effective date of disability? (MM/DD/YYYY) ______________________________________



When should individual be re-examined to determine extent of disability?(MM/DD/YYYY)_________________________

Is the individual able to engage in any substantial gainful business or occupation? (See “Person totally disabled” under



Definitions in separate instructions.)

Yes

Pertinent symptoms or findings that preclude the individual’s ability to engage in gainful work.

_______________________________________________________________________________________________________

CERTIFICATION BY PHYSICIAN, OPTOMETRIST, ETC.

I hereby certify that the above applicant conforms to the State definition of “Blind”, “Deaf”, or “Totally Disabled”. Sign this certification only if the applicant

meets the applicable definition.

Date of Certification

Signature of Certifying Professional

Professional License Number

Date License Expires

Print Name of Certifying Professional

State/Other Licensing Authority

Address of Certifying Professional

AUTHORIZATION FOR RELEASE OF INFORMATION BY BLIND APPLICANT

I hereby authorize the Department of Taxation, State of Hawaii, to release my name, social security number, address, information on my eye condition

and certification of my legal blindness as stated on tax Form N-172, to Ho’opono Services for the Blind Branch, Department of Human Services, State of

Hawaii. The purposes of sharing this information are to maintain a State register of persons who are legally blind as mandated by section 347-6, Hawaii

Revised Statutes, and to apprise me of services available from Ho’opono Services for the Blind.

Print Full Name of Blind Applicant

Date

Address of Blind Applicant

Signature of Blind Applicant or witnessed X. If signed X used, two

Social Security Number of Blind Applicant

witnesses must sign

Witness #1 - Signature, If X used.

Witness #2 - Signature, If X used.

FORM N-172