PHYSICIAN’S CERTIFICATION OF
TOTAL AND PERMANENT DISABILITY
Rule 12D-16.002
Florida Administrative Code
Effective 11/12
I, , a physician licensed pursuant to Chapter 458 or Chapter 459,
Physician’s name
Florida Statutes, hereby certify that Mr. Mrs. Miss Ms.
Name of totally and permanently disabled person
Social Security Number* - - , is totally and permanently disabled as of January 1,
due to the following mental or physical condition(s):
Quadriplegia Paraplegia Hemiplegia Legal blindness
Other total and permanent disability requiring use of a wheelchair for mobility
Check here if patient is totally or permanently disabled but does not require a wheelchair for mobility.
It is my professional belief the above condition(s) render Mr. Mrs. Miss Ms.
totally and permanently disabled and the foregoing statements
are true, correct, and complete to the best of my knowledge and professional belief.
Signature Date
Address: (print)
Street City State Zip
Florida Board of Medicine or Osteopathic Medicine license number
Issued on
NOTICE TO TAXPAYER: Each Florida resident applying for a total and permanent disability
exemption must present to the county property appraiser, on or before March 1 of each year, a copy
of this form or a letter from the United States Department of Veterans Affairs or its predecessor. Each
form is to be completed by a licensed Florida physician.
NOTICE TO TAXPAYER AND PHYSICIAN: Section 196.131(2), Florida Statutes, provides that any
person who knowingly and willfully gives false information for the purpose of claiming homestead
exemption 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.
*Disclosure of your social security number is mandatory. It is required by sections 196.011(1) and 196.101(5),
Florida Statutes. The social security number will be used to verify taxpayer identity information and homestead
exemption information submitted to property appraisers.
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