Schedule Dis - Kansas Certificate Of Disability - 2009
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12009
KANSAS
DIS
CERTIFICATE OF DISABILITY
(Rev. 7/09)
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 2009. 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 2009 must not
exceed the limits set by the Social Security Administration for 2009: $11,760, 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 2009?
�
�
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 _______________________________
Page 18
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