Fillable Form Dis - Kansas Certificate Of Disability

DIS

2015

KANSAS

CERTIFICATE OF DISABILITY

Rev. 8-15

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 2015 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 2015 must not exceed the limits set by the Social Security Administration for 2015: $13,080 if the impairment is

other than blindness; $21,840 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 2015?



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.

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 ___________________________________

Form Dis - Kansas Certificate Of Disability - 2015