Hawaii Claim for Tax Exemption by Person with Impaired Sight or Hearing

Claim for Tax Exemption by Person with Impaired Sight or Hearing
Form N-172, Rev. 2020, Claim For Tax Exemption by Person with Impaired Sight or Hearing or by Totally Disabled Person and Physician's Certification
Clear Form
FORM

N-172
(REV. 2020)

STATE OF HAWAII — DEPARTMENT OF TAXATION

Claim for Tax Exemption by Person with Impaired
Sight or Hearing or by Totally Disabled Person
and Physician’s Certification

(NOTE: References to “married” and “spouse” are also references to “in a civil union” and “civil union partner,” respectively.)
If you are submitting Form N-172 in response to either an adjustment letter or a collection notice, please check here ä



Part I Claim for tax exemption
INDIVIDUAL:

CORPORATION, PARTNERSHIP, or LLC:

Name of Individual 			

Name of Corporation, Partnership, or LLC		

Individual’s Social Security No.	

Federal Employer I.D. No.			

Street Address of Individual			

Street Address			

City, State & Postal/ZIP Code			

City, State & Postal/ZIP Code			

all of whose shareholders, partners, or members are individuals who are
who is (check applicable category)

(check all applicable categories)

	 A person who is blind as defined in sec. 235-1, HRS,

	 Blind as defined in sec. 235-1, HRS,

	 A person who is deaf as defined in sec. 235-1, HRS,

	 Deaf as defined in sec. 235-1, HRS,

	A person totally disabled as defined in sec. 235-1, HRS,

	 Persons totally disabled as defined in sec. 235-1, HRS,

hereby claims the benefits provided under the General Excise Tax and/or Income Tax Laws. (Check all applicable categories and provide the information
requested. See separate instructions for the definitions of blind, deaf, and person totally disabled.)

  General Excise Tax (sections 237-17 and 237-24(13), HRS)
(a)	 General Excise Hawaii Tax I.D. No. GE ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___ - ___ ___

(b)	 Doing Business As (DBA)		

(c)	 Business Address		

(d)	 Type of Business Activity		
(e)	 Individual’s Percentage of Ownership:	

; Spouse’s percentage:	

			
I declare, under the penalties set forth in section 231-36, HRS, that I have examined/understand the detail contents of this claim and to the best
of my knowledge and belief, it is true, correct, and complete.
IN THE CASE OF A CORPORATION, PARTNERSHIP, OR LLC, THIS FORM MUST BE SIGNED BY AN OFFICER, PARTNER OR MEMBER, OR DULY AUTHORIZED AGENT.

Taxpayer Signature (individual, corporate officer, partner or member, or duly authorized agent)		

Date	

Title	

NOTE:	 DISABILITY OR IMPAIRMENT MUST BE CERTIFIED BY LICENSED PHYSICIANS,
OPTOMETRISTS, ETC., ON THE BACK OF THIS FORM.

		
FORM N-172
N172_I 2020A 01 VID01

ID NO 01

FORM N-172
(REV. 2020)	

PAGE 2

Applicant’s Name  ____________________________________ 	
	 Part II

Social Security Number   __________________________

Physician’s or optometrist’s certification. Complete only one section, even if applicant has multiple disabilities.
This form may be rejected if the appropriate section and the certification are not fully completed. If
Section A is completed, sign authorization for release of information located at the bottom of this page.

SECTION A — EYE EXAMINATION	

(Must be done by a qualified ophthalmologist or optometrist.)

1.	Diagnosis______________________________________________________________________
2.	 Vision 1)  without corrective lenses:	 OD:________ 	OS:________ 	 2)  with corrective lenses:	
OD:________ 	OS:_______
3.	 Is this applicant’s visual acuity 20/200 or worse in the better eye with corrective lenses?		  Yes	
 No
4.	 Is the widest diameter of the field of vision less than 20 degrees? 	
 Yes	
 No
5.	 Date first certifiable as legally “blind” (MM/DD/YYYY)____________________________________
6.	 Should applicant be re-examined for tax purposes?	
 Yes	
 No	
If “Yes,” when?______________________
	(Must be done by a qualified otolaryngologist; i.e., Board-certified ear,
SECTION
B — HEARING EXAMINATION nose & throat specialist, or a licensed audiologist.)
		
1.	Diagnosis_________________________________________________________________________________________
2.	 Hearing loss (500-2000 Hertz) without aid:	 Right_______________ 	Left________________   (Decibels ASA or ANSI 1969)
3.	 Is the applicant’s average loss in speech frequencies (500-2000 Hertz) in the better ear, 82 Decibels ASA
	
(or 92 Decibels ANSI 1969) or worse?	
 Yes	
 No
4.	 Date first certifiable as legally “deaf”(MM/DD/YYYY)_____________________________________
5.	 Should applicant be re-examined for tax purposes?	
 Yes 	
 No	
If “Yes,” when?______________________
	 (Must be done by physicians as described in the definition for “person
SECTION
C — REPORT ON DISABILITY totally disabled” under section 235-1, Hawaii Revised Statutes.)
		
1.	Diagnosis_________________________________________________________________________________________
2.	 Date individual came under your care ____________  Date individual first disabled or unable to work________________
3.	 Is the individual totally disabled, either physically or mentally?     Yes     No
4.	 Is the disability permanent? (See “Person totally disabled” under Definitions in separate instructions.)
	
 Yes    What is the effective date of disability? (MM/DD/YYYY) ______________________________________
	
 No   When should individual be re-examined to determine extent of disability?(MM/DD/YYYY)_________________________
5.	 Is the individual able to engage in any substantial gainful business or occupation? (See “Person totally disabled” under
	
Definitions in separate instructions.)       Yes     No
6.	 Pertinent symptoms or findings that preclude the individual’s ability to engage in gainful work.
	
________________________________________________________________________________________________________

CERTIFICATION BY PHYSICIAN, OPTOMETRIST, ETC.
I hereby certify that the above applicant conforms to the State definition of “Blind,” “Deaf,” or “Totally Disabled.” Sign this certification only if the applicant
meets the applicable definition.
Date of Certification		

Signature of Certifying Professional 	

Professional License Number               Date License Expires		 Print Name of Certifying Professional	

State/Other Licensing Authority		

Address of Certifying Professional	

AUTHORIZATION FOR RELEASE OF INFORMATION BY BLIND APPLICANT
I hereby authorize the Department of Taxation, State of Hawaii, to release my name, social security number, address, information on my eye condition
and certification of my legal blindness as stated on tax Form N-172, to Ho’opono Services for the Blind Branch, Department of Human Services, State of
Hawaii. The purposes of sharing this information are to maintain a State register of persons who are legally blind as mandated by section 347-6, Hawaii
Revised Statutes, and to apprise me of services available from Ho’opono Services for the Blind.

Print Full Name of Blind Applicant	

Date	

Address of Blind Applicant

Signature of Blind Applicant or witnessed X. If signed X used, two	
witnesses must sign

Social Security Number of Blind Applicant

Witness #1 - Signature, If X used.		

Witness #2 - Signature, If X used.