PHYSICIAN'S CERTIFICATION OF TOTAL AND PERMANENT DISABILITY
I, ...(name of physician)..., a physician licensed pursuant to chapter 458 or chapter 459, Florida Statutes, hereby certify Mr. ...... Mrs. ...... Miss ...... Ms. ...... ......(name of totally and permanently disabled person)..., social security number ......, is totally and permanently disabled as of January 1, ...(year)..., due to the following mental or physical condition(s):
...... Quadriplegia
...... Paraplegia
...... Hemiplegia
...... Other total and permanent disability requiring use of a wheelchair for mobility
...... Legal Blindness
It is my professional belief that the above-named condition(s) render Mr. ...... Mrs. ...... Miss ...... Ms. ...... ...(name of totally and permanently disabled person)... totally and permanently disabled, and that the foregoing statements are true, correct, and complete to the best of my knowledge and professional belief.
Signature ................................................
Address (print) ............................................
Date ....................................................
Florida Board of Medicine or Osteopathic Medicine license number.....
Issued on.................................................
NOTICE TO TAXPAYER: Each Florida resident applying for a total and permanent disability exemption must present to the county property appraiser, on or before March 1 of each year, a copy of this form or a letter from the United States Department of Veterans Affairs or its predecessor. Each form is to be completed by a licensed Florida physician.
NOTICE TO TAXPAYER AND PHYSICIAN: Section 196.131(2), Florida Statutes, provides that any person who shall knowingly and willfully give false information for the purpose of claiming homestead exemption shall be guilty of a misdemeanor of the first degree, punishable by a term of imprisonment not exceeding 1 year or a fine not exceeding $5,000, or both.
OPTOMETRIST'S CERTIFICATION OF TOTAL AND PERMANENT DISABILITY
I, (name of optometrist) , an optometrist licensed pursuant to chapter 463, Florida Statutes, hereby certify that Mr. Mrs. Miss Ms. (name of totally and permanently disabled person) , social security number, is totally and permanently disabled as of January 1, (year) , due to legal blindness.
It is my professional belief that the above-named condition renders Mr. Mrs. Miss Ms. (name of totally and permanently disabled person) totally and permanently disabled and that the foregoing statements are true, correct, and complete to the best of my knowledge and professional belief.
Signature
Address (print)
Date
Florida Board of Optometry license number
Issued on
NOTICE TO TAXPAYER: Each Florida resident applying for a total and permanent disability exemption must present to the county property appraiser, on or before March 1 of each year, a copy of this form or a letter from the United States Department of Veterans Affairs or its predecessor. Each form is to be completed by a licensed Florida optometrist.
NOTICE TO TAXPAYER AND OPTOMETRIST: Section 196.131(2), Florida Statutes, provides that any person who knowingly and willfully gives false information for the purpose of claiming homestead exemption commits a misdemeanor of the first degree, punishable by a term of imprisonment not exceeding 1 year or a fine not exceeding $5,000, or both.
Fla. Stat. § 196.101
Former s. 192.113.