Certication of Disability
for Property Tax Exclusion (G.S. 105-277.1)
State of North Carolina
AV-9A
Web
6-11
CERTIFICATION OF DISABILITY: I afrm that I am qualied and authorized to make this determination.
Yes No I certify that the applicant is currently totally and permanently disabled as dened above in G.S. 105-277.1(b)(4).
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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.
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Address
City
Applicant’s Name
Zip CodeState
Home Telephone Number Work Telephone Number Cell Phone NumberExt.
Social Security Number
Date of Birth
Social Security Number (SSN) disclosure is mandatory for approval of the Property Tax Exclusion under G.S. 105-277.1 and will be used to establish
the identication of the applicant. The SSN may be used for verication of information provided on this application. The authority to require this number
is given by 42 U.S.C. Section 405(c)(2)(C)(i). The SSN and all income tax information will be kept condential. 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 (G.S. 105-277.1C). 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 qualication for disability benets.
Evidence that someone receives disability payments is not evidence of total and permanent disability.
Denition: G.S. 105-277.1(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.
Signature Date
Please submit completed certication to your County Tax Assessor. Do not submit to the N.C. Department of Revenue.
Print Name Phone
Title License Number
Name of Medical Practice or Government Agency
