OPTOMETRIST’S CERTIFICATION OF
TOTAL AND PERMANENT DISABILITY
I, , an optometrist licensed pursuant to Chapter 463,
Optometrist’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 legal blindness.
It is my professional belief the above-named condition renders Mr. Mrs. Miss Ms.
totally and permanently disabled and the foregoing
Name of totally and permanently disabled person
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 Optometry 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 optometrist.
NOTICE TO TAXPAYER AND OPTOMETRIST: 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(7),
Florida Statutes. The social security number will be used to verify taxpayer identity information and homestead
exemption information submitted to property appraisers.
DR-416B
R. 11/12
Rule 12D-16.002
Florida Administrative Code
Effective 11/12
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