Form Dis - Kansas Certificate Of Disability - 2014
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Page 11
DIS
2014
KANSAS
CERTIFICATE OF DISABILITY
(Rev. 8/14)
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 2014 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 2014
must not exceed the limits set by the Social Security Administration for 2014: $12,840 if the impairment is other than blindness;
$21,600 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 2014?
‰
‰
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.
I declare under the penalties of perjury that to the best of my knowledge and belief, this is a true, correct and complete statement.
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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