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2020 KANSAS
CERTIFICATE OF DISABILITY
If you are claiming homestead benets because of disability, this form must be completed by a duly licensed physician and
enclosed with your Homestead Claim, Form K-40H. Instead of this schedule, you may enclose a copy of your Social Security
certication of disability letter that shows you are receiving benets based upon a total and permanent disability which prevented
you from being engaged in any substantial gainful activity during the entire calendar year of 2020. You may enclose a copy of
your original Veterans Disability Statement or request a letter from your regional Veterans Administration that includes your
disability date and percentage of permanent disability. Annual income derived from any substantial gainful activity during 2020
must not exceed the limits set by the Social Security Administration for 2020: $15,120 if the impairment is other than blindness;
$25,320 if the individual is blind.
NAME OF PERSON EXAMINED __________________________________________________________________________________________________________________________________________________
SOCIAL SECURITY NUMBER ______________________________________________________________________________________________________________________________________________________
ADDRESS
Street or RR (Include apartment number or lot number)
_____________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________
City State Zip Code
1. Does the individual qualify as having a disability preventing them from engaging in any substantial gainful activity by reason
of any medically determinable physical or mental impairment which can be expected to result in death and/or has lasted
for the entire year of 2020?
o YES o NO
2. Nature of disability __________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________
3. When was the condition originally diagnosed? _______________________________________________________________________________________________________________________
CERTIFICATION OF PHYSICIAN
I, , certify that I have personally examined the physical
and mental condition of the above named individual.
______________________________________________________________________________________________________________
I declare under the penalties of perjury that to the best of my knowledge and belief, this is a true, correct and complete statement.
SIGNATURE OF PHYSICIAN ______________________________________________________________________________________________________________________________________________________
PHYSICIAN’S NAME
Please type or print
____________________________________________________________________________________________________________________________________________________________________
BUSINESS ADDRESS
Street or RR
_________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________
City State Zip Code
PHONE __________________________________________________________________________________________ DATE _________________________________________________________________
DIS
(Rev. 7-20)
130318
