CERTIFICATION OF DISABILITY FOR PROPERTY TAX EXEMPTION
Pursuant to Article IX, Sections 2, 2.1, 2.2, and 2.3 of the Arizona Constitution, A.R.S. Title 42, Chapter 11, Article 3, § 42-11111 and
Article 4, §§ 42-11151, 42-11152, 42-11153, and Arizona Administrative Code R15-4-116.
This form can be completed on-line and then printed, or it can be printed and completed manually. To assure that the
exemption afdavit (DOR 82514) is processed for the current Tax Year, if hand-delivered, the copy of this form which has
the applicant’s and the physician’s or psychiatrist’s signatures MUST be led along with the copy of the DOR 82514 Afdavit
of Individual Exemption form with the County Assessor of the county in which the applicant’s property is located no later
than the last business day in February. If this form and the DOR 82514 are mailed to the County Assessor, they must be
postmarked on or before the last business day of February.
Applicant’s Name:
(Type or Print) (Last) (First) (Initial)
Address:
(Street)
(City) (State) (Zip)
Date of Birth: Marital Status: Single Married
Applicant’s Signature: Date Signed:
Pursuant to Arizona Administrative Code R15-4-116: Exemption for Totally and Permanently Disabled Person
A. For purposes of the property tax exemption in the Arizona Constitution Article 9, Section 2.2, a person is “totally and
permanently disabled” if the person is unable to engage in any substantial gainful activity, for pay or prot, by reason of
any physical or mental impairment that is expected to:
1. Last for a continuous period of 12 months or more, or
2. Result in death within 12 months.
B. To qualify for the exemption, a disabled person shall be certied as totally and permanently disabled by a person licensed
under:
1. A.R.S. Title 32, Chapter 8, 13, 14, 17, 19.1, or 29; or
2. The laws of another state that are comparable to the laws governing persons qualifying under subsection (B)(1).
MEDICAL CERTIFICATION FOR TOTALLY AND PERMANENTLY DISABLED PERSONS
THE FOLLOWING IS TO BE COMPLETED BY THE EXAMINING PHYSICIAN OR PSYCHIATRIST:
I hereby certify the applicant’s condition as stated below:
The above-named applicant is unable to engage in any substantial gainful activity and therefore is considered to be totally
and permanently disabled as dened above. YES NO
Type or Print
Physician or Psychiatrist’s Name
Business Address
City State Zip
Telephone Number
Physician or Psychiatrist’s Signature Date
DOR 82514B (12/2011)
Physician’s or Psychiatrist’s Ofce Stamp:
