130318
                                   2019 KANSAS
DIS(Rev. 7-19)                     CERTIFICATE OF DISABILITY

  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 2019. You may enclose a copy of 
your original Veterans Disability Statement or request a letter from your regional Veterans Administration that includes your 
disability date and percentage of permanent disability. Annual income derived from any substantial gainful activity during 2019 
must not exceed the limits set by the Social Security Administration for 2019: $14,640 if the impairment is other than blindness; 
$24,480 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 2019?
                                   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                                                    State          Zip Code

PHONE _______________________________________________________                  DATE  _______________________________________