Fillable ITR DD Confirmation Of Diagnosis Of Disability External Form (SA Revenue Service)

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ITR DD Confirmation Of Diagnosis Of Disability External Form (SA Revenue Service)

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The ITR DD Confirmation Of Diagnosis Of Disability External Form (SA Revenue Service) form is 6 pages long and contains:

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Country of origin: SOUTH-AFRICA
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ITR - DD
Confirmation of Diagnosis of Disability
(To determine eligibility under section 6B of the Income Tax Act, 1962 (as amended)(the Act))
Instructions
This certificate must not be submitted with your tax return but must be retained and submitted to SARS only on request.
Complete Part A of this form. Remember to sign the authorisation area below.
Take this form to a duly registered medical practitioner trained to diagnose the applicable disability or to express an opinion on it.
Part A - Details of the Person with a Disability (To be completed by a person with the disability or his or her parent / guardian / curator where applicable)
Personal Details
Surname
First Two
Names
Home
Tel No.
Initials
Date of Birth
(CCYYMMDD)
ID No.
Bus
Tel No.
Passport
No.
Cell
No.
Fax
No.
Passport
Country
Contact
Email
Physical Details
Unit No.
Complex (if
applicable)
Street No.
Street / Farm
Name
Suburb /
District
City / Town
Postal Code
Postal Details
Mark here with an “X” if same as
above or complete your Postal
Address
Postal Code
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Part A - Details of the Person Claiming the Deduction (If different from page 1)
Personal Details
Surname
First Two
Names
Bus
Tel No.
Home
Tel No.
Initials
ID No.
Date of Birth
(CCYYMMDD)
Fax
No.
Cell
No.
Passport
No.
Passport
Country
Contact
Email
Indicate the person with a disability’s relationship to you:
Child
Other
Spouse
Specify
Physical Details
Unit No.
Complex (if
applicable)
Street No.
Street / Farm
Name
Suburb /
District
City / Town
Postal Code
Postal Details
Mark here with an “X” if same as
above or complete your Postal
Address
Postal Code
Date
(CCYYMMDD)
For enquiries go to
www.sars.gov.za or call
+27 800 00 SARS (7277)
Authorisation
As the person with the disability or his or her parent / guardian / curator, I authorise the
duly registered medical practitioner(s) having the relevant medical / clinical records to
provide to, or discuss with, the South African Revenue Service the information contained
in those records or on this certificate for purposes of determining whether or not I meet
the criteria for disability as defined under section 6B(1) of the Act.
Signature
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Part B - Diagnostic Criteria (To be completed by a duly registered medical practitioner trained to diagnose the applicable disability or to express an opinion on it)
Your patient must be a person with a disability as defined in Section 6B(1) of the Act. In this section –“Disability” means a moderate to severe limitation of
any person’s ability to function or perform daily activities as a result of a physical, sensory, communication, intellectual or mental
impairment, if the limitation—
(a) has lasted or has a prognosis of lasting more than a year; and
(b) is diagnosed by a duly registered medical practitioner in accordance with criteria prescribed by the Commissioner.
“Moderate to severe limitation”, in the context of disability means a significant restriction on a person’s ability to function or perform one or more basic daily
activities after maximum correction, except where indicated. Maximum correction in this context means appropriate therapy, medication and use of devices.
The diagnostic criteria seek to assess the functional impact of the impairment on a person’s ability to perform daily activities and not to diagnose a medical
condition.
Please complete the section(s) that apply to your patient.
Please remember to complete and sign Part C of this form.
Notes before completing this section
Medical Practitioner Requirements
Disability
Duly registered medical practitioner trained to diagnose the applicable disability
or to express an opinion thereon.
Vision
Practitioner trained to use the Snellen chart (e.g. an optometrist or ophthalmologit).
Hearing
Practitioner trained to perform or conduct a battery of the Diagnostic Audiometry tests.
(e.g. an Ear, Nose and Throat Specialist or Audiologist).
Speech
E.g. Speech-Language Pathologist
Physical
E.g. Orthopaedic Surgeon, Neuro Surgeon, Physiotherapist or Occupational Therapist.
Intellectual
E.g. Psychiatrist or Clinical Psychologist
Mental
E.g. Psychiatrist or Clinical Psychologist
Vision
It is SARS’s policy, in determining whether a person has a disability for the purposes of section 6B of the Act, to follow the guidelines
specified by the World Health Organisation. The minimum requirement for a person to be classified as a person with a disability is as
follows:
Communication
Applicable
Applicable
For purposes of section 6B of the Act, a person is regarded as having a moderate to severe communication disability if he or she has any
one or a combination of the following, which even with appropriate therapy, medication and devices, substantially limits (that is, more
than inconvenient or bothersome) one or more major life activity below that is age-appropriate:
Inability to make self understood to familiar communication partners using speech in a quiet setting;
Inability to make self understood, to familiar and or non-familiar communication partners and to meet communication needs as
appropriate for his/her age by using speech, in less than 30 intelligible words;
Problems in understanding meaningful language by familiar communication partners that lead to substantial difficulty in
communicating or
The need to rely on augmentative or alternative communication (AAC), including unaided (Sign language or other manual signs) or
aided means of communication (ranging from communication boards to speech generating devices).
Is your patient’s impairment in accordance with these criteria?
If Yes, when did your patient for the first time meet these criteria? (CCYYMM)
Y
N
Is your patient’s impairment in accordance with these criteria?
N
Y
If Yes, when did your patient for the first time meet these criteria? (CCYYMM)
Disability
Minimum Requirement
Visual Acuity
In the better eye with best possible correction, less than 6/18 (0.3).
Visual Field
10 degrees or less around central fixation.
“6/18” means that what a person with normal vision can read at 18 metres, the person being tested can only read at 6 metres.
“Best possible correction” refers to the position after a person’s vision has been corrected by means of spectacles, contact lenses or
intra-ocular (implanted) lenses.
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Part B - Diagnostic Criteria (Continued)
Physical
A person is regarded as a person with a disability if his or her impairment is to such an extent that he or she –
Is unable to walk, for example, wheelchair user;
Is able to walk only with the use of assistive devices, for example, callipers, crutches, walking frames and other such devices;
Is able to walk without the use of assistive devices but with a degree of difficulty, for example, persons with Cerebral Palsy, Polio
etc (that is, requires inordinate amount of time to walk);
Is functionally limited in the use of their upper limbs.
Mental
Applicable
Applicable
With the exclusion of intellectual disability, a person is regarded to be a person with a mental disability if he or she has been diagnosed,
in terms of accepted diagnostic criteria (Diagnostic and Statistical Manual (DSM V)) by a mental health care practitioner authorised to
make such diagnosis, with a mental impairment that disrupts daily functioning and this impairment moderately or severely interferes or
limits the performance of major life activities, such as learning, thinking, communicating and sleeping, among others.
Notes:
Moderate impairment means a Global Assessment Functioning Score (GAF-Score) between 31 and 60; and
Severe impairment means GAF-Score of 30 and below.
Is your patient’s impairment in accordance with these criteria?
If Yes, when did your patient for the first time meet these criteria? (CCYYMM)
Y
N
Is your patient’s impairment in accordance with these criteria?
N
Y
If Yes, when did your patient for the first time meet these criteria? (CCYYMM)
Hearing
Hearing disability is defined as the functional limitations resulting from a hearing impairment. Hearing impairment is a sensory impairment
that will influence verbal communication between speaker and listener.
1. An adult is considered moderately to severely hearing impaired when the hearing loss is described as follows without the use of an
amplification device/s:
Bilateral hearing loss with a pure tone average equal to or greater than 25 dBHL in each ear.
Unilateral hearing loss with pure tone average equal to or greater than 40 dBHL in the affected ear.
2. A child is considered moderately to severely hearing impaired when the hearing loss is described as follows without the use of an
amplification device/s:
Bilateral hearing loss with a pure tone average greater than 15 dBHL in each ear;
Unilateral hearing loss with a pure tone average equal to or greater than 20 dBHL in the affected ear.
Notes:
Hearing impairment is an abnormal or reduced function in hearing resulting from an auditory disorder.
A child is a person between the ages of 0 to 18 years.
Amplification devices include hearing aids, implantable devices and assistive listening devices.
Pure Tone Average (PTA): average of hearing sensitivity thresholds (in decibel hearing level) to pure tone signals at 500 Hz & 1000
Hz, 2000 Hz & 4000 Hz of each ear.
Bilateral hearing loss is a hearing sensitivity loss in both ears.
Unilateral hearing loss is a hearing sensitivity loss in one ear only.
Applicable
Is your patient’s impairment in accordance with these criteria?
If Yes, when did your patient for the first time meet these criteria? (CCYYMM)
Y
N
Intellectual
Applicable
A person is regarded to be a person with an intellectual disability if he or she has a moderate to severe impairment in intellectual
functioning that is accompanied by a significant limitation in adaptive functioning in at least two of the following skill areas:
Communication
Self-care
Home living
Social/Interpersonal skills
Use of community resources
Self-direction
Functional academic skills, work, leisure, health and safety.
Notes:
Moderate impairment means an Intelligence Quotient (IQ) between 35 and 49; and
Severe impairment means IQ of 34 and below.
Is your patient’s impairment in accordance with these criteria?
N
Y
If Yes, when did your patient for the first time meet these criteria? (CCYYMM)
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Part C - Certification (To be completed by a duly registered medical practitioner trained to diagnose the applicable disability or to express an opinion on it)
1. Considering the diagnostic criteria in Part B, do you consider the functional limitations of the applicable disability or disabilities on your patient’s ability to perform activities of daily living, to be -
Mild
Moderate to
Severe
2. If the answer to the above question is ‘moderate to severe’, describe the functional impact of the impairment(s) on your patient’s ability to perform activities of daily living. If more space is required, attach a separate sheet of paper.
3. Has your patient’s disability lasted, or is it expected to last for a continuous period of more than 12 months?
Yes
No
Note:
If the impairment(s) are moderate to severe and has lasted or has a prognosis of lasting more than 12 months, your patient will be regarded as a person with disability as defined in section
6B(1) of the Act.
Date of determination
(CCYYMMDD)
For enquiries go to
www.sars.gov.za or call
+27 800 00 SARS (7277)
Declaration
As a duly registered medical practitioner, I certify that to the best of my knowledge the
information given in Part C of this form is correct and complete and I understand that
this information will be used by the South African Revenue Service to to determine if my
patient is a person with a disability as defined in section 6B(1) of the Act.
Signature
Practice Stamp
4. If the answer to question 1 is ‘moderate to severe’ and the answer to question 3 is Yes, is the disability of a permanent nature?
Yes
No
Note:
a) If the answer to question 4 is Yes, please note:
If your patient qualified as a person with a disability for the first time on or after 1 March 2019, this certificate will be valid for ten (10) years, provided the disability remains
moderate to severe.
If your patient qualified as a person with a disability for the first time before 1 March 2019 and if, on 1 March 2019, the person has a valid existing ITR-DD form which expires
after this date, that ITR-DD form will be valid for a further period of five (5) years following the date of expiry of that form and it is therefore not necessary to complete a new
ITR-DD until date of expiry of that form, provided the disability remains moderate to severe.
b) If the answer to question 4 is No, please note:
If your patient qualified as a person with a disability for the first time in the 2020 year of assessment or years of assessment prior to 2020, this certificate will be valid for the
period of 1 year from 1 March 2019.
If your patient qualified as a person with a disability for the first time after the 2020 year of assessment, this certificate will be valid for the period of 1 year from 1 March of the year of
assessment in which the duly registered medical practitioner signed this form.
5. Considering the above, as a duly registered medical practitioner, I certify that this person is (please select the applicable):
Person with disability as defined
in section 6B(1) of the Act
Person without a disability
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Part D - Details of Registered Practitioner
Personal Details
Surname
First Two
Names
Cell No.
Bus
Tel No.
Initials
ID No.
Date of Birth
(CCYYMMDD)
Email
Profession
(e.g. an Optometrist, Ophthalmologist, Ear, Nose and Throat Specialist, Audiologist, Speech-Language Pathologist, Orthopaedic Surgeon, Neuro Surgeon, Physiotherapist, Occupational Therapist, Psychiatrist, Clinical Psychologist etc.)
Physical Details
Unit No.
Complex (if
applicable)
Street No.
Street / Farm
Name
Suburb /
District
City / Town
Postal Code
Postal Details
Mark here with an “X” if same as
above or complete your Postal
Address
Postal Code
Print
Save
Reset
Email
Print PDF
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ITR DD Confirmation Of Diagnosis Of Disability External Form (SA Revenue Service)

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Completed 3 July 2021

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