MARK CHURCH
EF-62-A-R04-0810-41000466-1                                                                                                                                   Assessor - County Clerk - Recorder
BOE‑62‑A REV. 04 (08‑10)                                                                                                                                      555 County Center
CERTIFICATECERTIFICA          OF DISABILITYTE OF DISABILITY                                                                                                   Redwood City, CA 94063
The claimant listed below has applied to transfer his or her property tax                                                                                     P 650.363.4500    F 650.599.7435
                                                                                                                                                              email assessor@smcacre.org
base  to  a  replacement  property  as  provided  by  section  69.5  of  the                                                                                  web www.smcacre.org
Revenue and Taxation Code. In order to qualify for this one time tax 
benefit, a licensed physician or surgeon of appropriate specialty must 
certify the disability of the claimant, or claimant’s spouse, is both severe 
and permanent. The definition for a severely and permanently disabled 
person is, “. . . any person who has a physical disability or impairment, 
whether from birth or reason of accident or disease, including, but not 
limited  to,  any  disability  or  impairment  which  affects  sight,  speech, 
hearing or use of any limbs and which results in a functional limitation as 
to employment or substantially limits one or more major life activities of 
that person, and which has been diagnosed as permanently affecting the 
person’s ability to function.” (Revenue and Taxation Code section 74.3)
I.  I.   TO BE COMPLETED BY A PHYSICIAN TO BE COMPLETED BY A PHYSICIAN (please print)(please print)

Patient’s name:                                                                                                                                               Date of disability:

Description of patient’s disability:

Identify:Identify:(1)(1)thethespecificspecificreasonsreasonswhywhythethedisabilitydisabilitynecessitatesnecessitatesaamovemovetotothethereplacementreplacementdwellingdwellingandand(2)(2)thethedisability‑relateddisability‑relatedrequirements,requirements, 
including any locational requirements, of a replacement dwelling:including any locational requirements, of a replacement dwelling:

I am a licensed                physician                           surgeon. My specialty is: 
                                                                                                   CERTIFICATION
       I certify that in my medical opinion the above named patient does qualify as a disabled person according to the definition above.
PhySICIAn’S SIgnATuRE                                                                                                                                                                                                               DATE
t
PhySICIAn’S nAME (print or type)                                                                                                                                                                                                    DAyTIME PhOnE nuMBER
                                                                                                                                                                                                                                    (   )
II. TO BE COMPLETED BY CLAIMANT, CLAIMANT’S SPOUSE OR LEGAL GUARDIAN (please print)
CLAIMAnT’S nAME                                                                                                                         SPOuSE’S nAME

PROPERTy ADDRESS                                                                                                                                                                    ASSESSOR’S PARCEL nuMBER

                                                                        CERTIFICATE OF DISABILITYCERTIFICATE OF DISABILITY  (check A or B)(check A or B)
    A:  1. The claimant or spouse must describe in his or her own words how the replacement dwelling meets the disability‑related requirements 
                        identified in Part I (Part I must be completed by a physician):

                                                                                                                                  ANDAND
                  2. 2. I certify (or declare) under penalty of perjury under the laws of the State of California that the primary purpose of the move to theI certify (or declare) under penalty of perjury under the laws of the State of California that the primary purpose of the move to the
                        replacement dwelling is to satisfy the identified disability‑related requirements described in Part I.replacement dwelling is to satisfy the identified disability‑related requirements described in Part I.
                                                                                                                                   OR
    B:            I certify (or declare) under penalty of perjury under the laws of the State of California that the primary purpose of the move to the 
                  replacement dwelling is to alleviate the financial burdens caused by the disability.
SIgnATuRE OF CLAIMAnT                                                                                                                   DAyTIME PhOnE nuMBER                                                                        DATE
t                                                                                                                                       (            )
SIgnATuRE OF SPOuSE                                                                                                                     DAyTIME PhOnE nuMBER                                                                        DATE
t                                                                                                                                       (            )
E‑MAIL ADDRESS

                                                            THIS DOCUMENT IS NOT SUBJECT TO PUBLIC INSPECTION