Kansas Certificate of Disability

Certificate of Disability
2023 Homestead or Property Tax Refund for Homeowners Instruction Booklet Rev. 7-23
2023 KANSAS

DIS

CERTIFICATE OF DISABILITY

(Rev. 7-23)

DIS
Attach
130318

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 2023. 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 2023 must not exceed the limits set by the Social Security Administration for
2023: $17,640 if the impairment is other than blindness; $29,520 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 2023?
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

BUSINESS ADDRESS _________________________________________________________________________________________________________________________________________________________________
Street or RR

______________________________________________________________________________________________________________________________________________________________________________________________________

City

PHONE_

State

DATE_

Zip Code