Clear Form

FORM                                                                      
                                          STATE OF HAWAII — DEPARTMENT                   OF TAXATION 
N-172 
(REV. 2020)           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   ___________________________________       Social Security Number    _________________________

 Part II     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       Social Security Number of Blind Applicant 
 witnesses must sign

 Witness #1 - Signature, If X used.                                        Witness #2 - Signature, If X used.