Kansas Certificate of Disability

Certificate of Disability
2024 - DIS - Certificate of Disability Revised_7-24
DIS

2024 KANSAS

CERTIFICATE OF DISABILITY

(Rev. 7-24)

DIS
Attach
130324

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 2024. You must enclose a copy of
your original Veterans Disability Statement or letter with all required information, including your disability date and percentage
of permanent disability, from the V.A. when claiming a Disabled Veterans disability for homestead and SVR. Annual income
derived from any substantial gainful activity during 2024 must not exceed the limits set by the Social Security Administration
for 2024: $18,600 if the impairment is other than blindness; $31,080 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 2024?
o YES
o 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

_

PHONE_

DATE_________________________________________________________________

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