PHYSICIAN’S AFFIDAVIT
OF
PERMANENT AND TOTAL DISABILITY
PT-PA-1
NAME OF PERSON EXAMINED__________________________________________________________________________
Address____________________________________________________________________________________________
City______________________________________________________State__________________Zip Code___________
I am actively providing treatment directly related to the permanent and total disability of the person named above
seeking this exemption. Yes_______ No_______
My professional opinion is that the person named above is permanently and totally disabled. Yes_______ No_______
The person named above seeking this exemption has been permanently and totally disabled since ____/_____/_____
AFFIDAVIT OF PHYSICIAN
I, _______________________________, certify that I have personally examined the physical condition of the
above named individual and determined him or her to be permanently and totally disabled. I understand that according
to Title 40-9-21.2 any person who knowingly and willfully gives false information for the purpose of claiming a
homestead exemption, or for the purpose of assisting another person in claiming a homestead exemption, shall be
ordered to pay twice the amount of any ad valorem tax which would have been due retroactive for a period of up to
10 years plus interest at a rate of 15 percent per annum from the date the tax would have been due.”
SIGNATURE OF PHYSICIAN_____________________________________________________________________________
PHYSICIAN NAME____________________________________________________________________________________
CURRENT ALABAMA MEDICAL LICENSE NUMBER____________ ISSUE DATE__________EXPIRATION DATE____________
BUSINESS ADDRESS__________________________________________________________________________________
CITY_____________________________________STATE_____________________________ZIP CODE________________
PHONE_________________________________ DATE______________________________
BALDWIN COUNTY REVENUE COMMISSIONER
§3.340 Total and permanent total ratings and unemployability.
(a)
Total disability ratings
(1) General. Total disability will be considered to exist when there is present any impairment of mind or
body which is sufficient to render it impossible for the average person to follow a substantially gainful
occupation. Total disability may or may not be permanent. Total ratings will not be assigned, generally, for
temporary exacerbations or acute infectious diseases except where specifically prescribed by the schedule.
(2) Schedule for rating disabilities. Total ratings are authorized for any disability or combination of
disabilities for which the Schedule for Rating Disabilities prescribes a 100 percent evaluation or, with less
disability, where the requirements of paragraph 16, page 5 of the rating schedule are present or where, in
pension cases, the requirements of paragraph 17, page 5 of the schedule are met.
(3) Ratings of total disability on history. In the case of disabilities which have undergone some recent
improvement, a rating of total disability may be made. provided:
(i) That the disability must in the past have been of sufficient severity to warrant a total disability rating;
(Il) That it must have required extended, continuous, or intermittent hospitalization, or have produced
total industrial incapacity for at least 1 year, or be subject to recurring, severe, frequent, or prolonged
exacerbations; and
(Iii) That it must be the opinion of the rating agency that despite the recent improvement of the physical
condition, the veteran will be unable to affect an adjustment into a substantially gainful occupation. Due
consideration will be given to the frequency and duration of totally incapacitating exacerbations since
incurrence of the original disease or injury, and to periods of hospitalization for treatment in determining
whether the average person could have reestablished himself or herself in a substantially gainful
occupation.
(b) Permanent total disability. Permanence of total disability will be taken to exist when such impairment is
reasonably certain to continue throughout the life of the disabled person. The permanent loss or loss of use
of both hands, or of both feet, or of one hand and one foot, or of the sight of both eyes. or becoming
permanently helpless or bedridden constitutes permanent total disability. Diseases and injuries of long
standing which are actually totally incapacitating will be regarded as permanently and totally disabling when
the probability of permanent improvement under treatment is remote. Permanent total disability ratings
may not be granted as a result of any incapacity from acute infectious disease, accident, or injury, unless
there is present one of the recognized combinations or permanent loss of use of extremities or sight, or the
person is in the strict sense permanently helpless or bedridden, or when it is reasonably certain that a
subsidence of the acute or temporary symptoms will be followed by irreducible totality of disability by way
of residuals. The age of the disabled person may be considered in determining permanence.
(c) Insurance ratings. A rating of permanent and total disability for insurance purposes will have no effect on
ratings for compensation or pension.
[26 FR 1585, Feb. 24, 1961, as amended at 46 FR 47541, sept. 29, 1981]
Physicians Signature Required_______________________________ Date____________
BAY MINETTE
251-937-0245
FAIRHOPE
251-928-3002, EXT. 2640
FOLEY
251-943-5061, EXT. 2840
ROBERTSDALE
251-970-4035, EXT. 4810
T
EDDY
J
.
F
AUST,
J
R.
MAILING ADDRESS:
COLLECTIONS: P.O. Box 1549
ASSESSMENTS: P.O. Box 1389
BAY MINETTE, ALABAMA 36507
www.baldwincountyal.gov
1705 U.S. HWY. 31 SOUTH