FIRST RESPONDER'S PHYSICIAN CERTIFICATE OF TOTAL AND PERMANENT DISABILITY
I, (name of physician) , a physician licensed pursuant to chapter 458 or chapter 459, Florida Statutes, hereby certify that Mr. Mrs. Miss Ms. (applicant name and social security number) , is totally and permanently disabled due to an impairment of the mind or body, and such impairment renders him or her unable to engage in any substantial gainful occupation, which condition is reasonably certain to continue throughout his or her life. Mr. Mrs. Miss Ms. (applicant name) has the following mental or physical condition(s):
It is my professional belief that within a reasonable degree of medical certainty, the above-named condition(s) render Mr. Mrs. Miss Ms. (applicant name) 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 an exemption due to a total and permanent disability that occurred in the line of duty while serving as a first responder must present to the county property appraiser the required physician certificate(s), the required documentation from the Social Security Administration, and a certificate from the employer for whom the applicant worked as a first responder at the time of the injury or injuries, as required by section 196.102(5), Florida Statutes. This form is to be completed by a licensed Florida physician.
NOTICE TO TAXPAYER AND PHYSICIAN: Section 196.102(10), Florida Statutes, provides that any person who knowingly and willingly gives false information for the purpose of claiming the homestead exemption for totally and permanently disabled first responders 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. § 196.102