Fillable Form Dis - Kansas Certificate Of Disability

DIS

2016

KANSAS

CERTIFICATE OF DISABILITY

(Rev. 8/16)

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 2016. 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 2016

must not exceed the limits set by the Social Security Administration for 2016: $13,560 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 2016?

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

DATE _______________________________________

PHONE_______________________________________________________

Page 11

Form Dis - Kansas Certificate Of Disability - 2016