Fillable Certi cate of Disability for the Homestead Exemption (Stark County Government)

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Certi cate of Disability for the Homestead Exemption (Stark County Government)

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BROWSE STARK COUNTY GOVERNMENT (OH) FORMS

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Attach this form to the homestead exemption application (form DTE 105A)
if the applicant is requesting the homestead exemption based on disability status.
Ohio Revised Code section 323.151: “ ‘Permanently and totally disabled’ means a person who has, on the fi rst day of Janu-
ary of the year of application for reduction in real estate taxes, some impairment in body or mind that makes the person un-
able to work at any substantially remunerative employment that the person is reasonably able to perform and that will, with
reasonable probability, continue for an indefi nite period of at least twelve months without any present indication of recovery
therefrom or has been certifi ed as permanently and totally disabled by a state or federal agency having the function of so
classifying persons.”
To be completed by the applicant
Applicant’s name
Home address
To be completed by the physician, psychologist or state or federal agency representative.
In accordance with the above, I (we) hereby certify that was, as of Jan. 1, ,
and is now permanently and totally disabled according to the above defi nition by virtue of physical disability or
mental disability.
License number and state issuing (Note: If reason for reduction is
mental disability, the physician or psychologist must hold an Ohio license.)
Physician (signature) Print name of person signing form
Psychologist (signature) Address (please print)
Agency (please print) City State ZIP code
If agency, signature and title of person completing the form Date
In lieu of having a physician or psychologist sign this form, the applicant may submit a statement from an eligible state or
federal agency that the applicant is permanently and totally disabled as defi ned above. See the back page of this form for
more information on what constitutes acceptable proof of permanent disability.
DTE 105E
Rev. 2/16
Certifi cate of Disability for the Homestead Exemption
Name of applicant
Alan Harold
Stark County Auditor
110 Central Plaza S
Suite 220
Canton OH 44702
(330) 451-7323
FAX (330) 451-7630
Reset Form
Acceptable and Unacceptable Proofs of Permanent and Total Disability
Physician’s Certifi cate: Acceptable. An application based
on physical disability must include a certifi cate signed by a
physician. An application based on mental disability must
include a certifi cate signed by a physician or a psychologist
licensed to practice in Ohio. Note: A chiropractor is not a
“physician” for purposes of the Homestead Law.
Federal Agencies:
Social Security Administration (SSA): An SSA (or SSI)
form indicating that an applicant is “disabled” is acceptable.
The SSA only gives disability benefi ts to those who are per-
manently and totally disabled.
Department of Veterans Affairs (VA): Veterans with a total
service-connected disability or veterans who are receiving
100% compensation for service-connected disabilities follow-
ing a determination of individual unemployability should fi le
DTE form 105I and submit the documentation indicated by
that application. If a veteran does not qualify as an eligible
disabled veteran, but meets the defi nition found in R.C.
323.151(D) (provided at the top of this form), the veteran
must have a doctor or qualifying psychologist complete this
form. No VA documentation refl ects the statutory defi nition
of permanent and total disability in R.C. 323.151(D).
Railroad Retirement Board (RRB): The RRB has two types
of disability pensions: (1) total and permanent disability and
(2) occupational disability. Only the “permanent and total
disability” pension is acceptable.
State Agencies:
Bureau of Workers Compensation: A determination of
“permanent and total disability” is acceptable. Other de-
terminations, such as “permanent and partial disability”
“temporary and total disability,” and “temporary and partial
disability” are not.
State Retirement Systems: Not acceptable. The Public
Employees Retirement System (PERS), the State Teachers
Retirement System and the School Employees Retirement
System (SERS), do not certify permanent and total disability.
While the State Highway Patrol Retirement System (HPRS)
and the Police and Firemen’s Disability and Pension Fund
(PFDPF) do certify individuals to be “permanently and totally
disabled” these determinations are job-specifi c and do not
rule out the possibility of other substantially remunerative
employment using a different set of skills.
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Certi cate of Disability for the Homestead Exemption (Stark County Government)

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Completed 18 July 2020

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