Form Dis - Kansas Certificate Of Disability 1999 printable pdf download

Form Dis - Kansas Certificate Of Disability 1999

KANSAS

1999

DIS

CERTIFICATE OF DISABILITY

If you are claiming benefits because of disability, this form must be completed by

a duly licensed physician and attached to your Homestead Claim. Instead of this

schedule, you may attach a copy of your Social Security certification of disability

letter showing proof that 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 1999. The annual income derived

from any gainful activity must not exceed $6,000.

NAME OF PERSON EXAMINED

ADDRESS

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 1999?

YES

2. Nature of disability.

3. When was the condition originally diagnosed?

Date

CERTIFICATION OF PHYSICIAN

, certify that I personally have

examined the physical and mental condition of the above named individual.

SIGNATURE OF PHYSICIAN

PHYSICIAN’S NAME

BUSINESS ADDRESS

DATE

Form Dis - Kansas Certificate Of Disability 1999