AV-9A                                                                                                                         4
Web                                          Certication of Disability                                                                   6
6-11                  for Property Tax Exclusion (G.S. 105-277.1)                                                             PRINT      CLEAR
                                             State of North Carolina

Applicant’s Name                                                                                        Social Security Number

Address                                                                                                 Date of Birth

City                                                                                                    State        Zip Code
                                                                                                         
Home Telephone Number                        Work Telephone Number Ext. Cell Phone Number

Social Security Number (SSN) disclosure is mandatory for approval of the Property Tax Exclusion under G.S. 105-277.1 and will be used to establish 
the identication of the applicant.  The SSN may be used for verication of information provided on this application.  The authority to require this number 
is given by 42 U.S.C. Section 405(c)(2)(C)(i).  The SSN and all income tax information will be kept condential.  The SSN may also be used to facilitate 
collection of property taxes if you do not timely and voluntarily pay the taxes.  Using the SSN will allow the tax collector to claim payment of an unpaid 
property tax bill from any State income tax refund that might otherwise be owed to you.  Your SSN may be shared with the State for this purpose.  In 
addition, your SSN may be used to garnish wages or attach bank accounts for failure to timely pay taxes.
DO NOT USE THIS FORM TO CERTIFY DISABILITY FOR THE DISABLED VETERAN EXCLUSION (G.S. 105-277.1C).  IT IS A DIFFERENT PROGRAM. 
YOU MUST OBTAIN A VETERAN’S DISABILITY CERTIFICATION DIRECTLY FROM THE APPROPRIATE FEDERAL AGENCY.

This section can only be completed by a physician licensed to practice medicine in North Carolina or by a governmental agency authorized to 
determine qualication for disability benets.
Evidence that someone receives disability payments is not evidence of total and permanent disability.
Denition:  G.S. 105-277.1(b)(4) Totally and permanently disabled. – A person is totally and permanently disabled if the person has a physical 
or mental impairment that substantially precludes him or her from obtaining gainful employment and appears reasonably certain to continue 
without substantial improvement throughout his or her life.

CERTIFICATION OF DISABILITY: I afrm that I am qualied and authorized to make this determination.
Yes        No    ► I certify that the applicant is currently totally and permanently disabled as dened above in G.S. 105-277.1(b)(4).    
Yes        No    ► I certify that the applicant was under my care as of January 1 of this year and was totally and permanently disabled on that date.   

Signature                                                               Date

Print Name                                                              Phone

Title                                                                   License Number

Name of Medical Practice or Government Agency

           Please submit completed certication to your County Tax Assessor.  Do not submit to the N.C. Department of Revenue.