Pennsylvania Physician's Statement of Permanent and Total Disability (PA Property Tax/Rent Rebate)

Physician's Statement of Permanent and Total Disability (PA Property Tax/Rent Rebate)
2023 Physician's Statement - Physician's Statement of Permanent and Total Disability (PA-1000 PS)
IMPORTANT: FILL IN FORM MUST BE DOWNLOADED ONTO YOUR COMPUTER PRIOR TO COMPLETING
PHYSICIAN’S STATEMENT

2305310050

Physician’s Statement of
Permanent and Total Disability
PA-1000 PS 03-23 (FI)
PA Department of Revenue

2023

OFFICIAL USE ONLY

START Name as shown on PA-1000

Social Security Number

➜
Instructions
A claimant not covered under the federal Social Security Act or the federal Railroad Retirement Act who is unable
to submit proof of permanent and total disability may submit this Physician’s Statement. The physician must determine the claimant’s status using the same standards used for determining permanent and total disability
under the federal Social Security Act or the federal Railroad Retirement Act. CAUTION: If the claimant applied
for Social Security disability benefits and the Social Security Administration did not rule in the claimant’s favor,
the claimant is not eligible for a Property Tax or Rent Rebate.
Confidentiality Statement. All information on this Physician’s Statement and claim form is confidential. The
department shall only use this information for the purposes of determining the claimant’s eligibility for a Property
Tax or Rent Rebate.
CERTIFICATION
I certify the claimant named above is my patient and is permanently and totally disabled under the standards that
the federal Social Security Act or the federal Railroad Retirement Act requires for determining permanent and total
disability. Upon request from the PA Department of Revenue, I will provide the medical reports or records indicating diagnosis and prognosis of the claimant’s condition, including signs, symptoms and laboratory findings, if
applicable or appropriate.

Please sign after printing.
Physician Signature

Date MM/DD/YY

Description of Claimant’s Permanent and Total Disability. Briefly describe the reason(s) the above-named
claimant is totally and permanently disabled.

Physician Identification Information. Please print.
Name

National Provider Identifier

Business name, if applicable
Address
City

State

Office telephone number

Office email address

2305310050
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ZIP Code

2305310050
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