AV-9A - Certification of Disability

10 AV - 9A Certification of Disability Web for Property Tax Exclusion GS 105 - 2771 6 - 11 State of North Carolina Applicant’s Name Social Security Number Address Date of Birth City State Zip Code Home Telephone Number Work Telephone Number Ext Cell Phone Number Social Security Number SSN disclosure is mandatory for approval of the Property Tax Exclusion under GS 105 - 2771 and will be used to establish the identification of the applicant The SSN may be used for verification of information provided on this application The authority to require this number is given by 42 USC Section 405 c 2 C i The SSN and all income tax information will be kept confidential The SSN may also be used to facilitate collection of property taxes if you do not timely and voluntarily pay the taxes Using the SSN will allow the tax collector to claim payment of an unpaid property tax bill from any State income tax refund that might otherwise be owed to you Your SSN may be shared with the State for this purpose In addition , your SSN may be used to garnish wages or attach bank accounts for failure to timely pay taxes DO NOT USE THIS FORM TO CERTIFY DISABILITY FOR THE DISABLED VETERAN EXCLUSION GS 105 - 2771C IT IS A DIFFERENT PROGRAM YOU MUST OBTAIN A VETERAN’S DISABILITY CERTIFICATION DIRECTLY FROM THE APPROPRIATE FEDERAL AGENCY This section can only be completed by a physician licensed to practice medicine in North Carolina or by a governmental agency authorized to determine qualification for disability benefits Evidence that someone receives disability payments is not evidence of total and permanent disability Definition GS 105 - 2771 b 4 Totally and permanently disabled – A person is totally and permanently disabled if the person has a physical or mental impairment that substantially precludes him or her from obtaining gainful employment and appears reasonably certain to continue without substantial improvement throughout his or her life CERTIFICATION OF DISABILITY I affirm that I am qualified and authorized to make this determination Yes No I certify that the applicant is currently totally and permanently disabled as defined above in GS 105 - 2771 b 4 ? Yes No I certify that the applicant was under my care as of January 1 of this year and was totally and permanently disabled on that date ? Signature Date Print Name Phone Title License Number Name of Medical Practice or Government Agency Please submit completed certification to your County Tax Assessor Do not submit to the NC Department of Revenue Page