NCDVA-9
(Rev. 08-09)
For best delivery to USDVA, filing this form with your local veteran's service office is recommended.
COUNTY
STATE ZIP CODE
I authorize the U.S. Department of Veterans Affairs to release information regarding my disability as needed for this
certification.
I authorize the U.S. Department of Veterans Affairs to release information regarding my spouse's disability or death
as needed for this certification.
A.
Veteran does not meet either B, C, D, or E of the below criteria.
B.
Veteran received benefits on ______________________ from U.S. Department of Veterans Affairs for specially
adapted housing under 38 U.S.C. 2101 for the veteran's permanent residence.
D.
Veteran died on _______________________ and had a service-connected permanent and total disability at death.
E.
Honorable Under Other than Honorable Conditions
Under Honorable Conditions
DATESIGNATURE OF USDVA CERTIFYING OFFICIAL
PRINTED NAME OF USDVA CERTIFYING OFFICIAL
TITLE OF USDVA CERTIFYING OFFICIAL
Veteran died on _______________________ and the death was either (1) the result of a service-connected condition or
(2) death occurred while on active duty in the line of duty and not due to service member's own willful misconduct.
I am either (1) a veteran whose character of service at separation was honorable or under honorable conditions and who has a permanent
and total service-connected disability or (2) the surviving spouse, who has not remarried, of a veteran whose character of service at
separation was honorable or under honorable conditions and who had a permanent and total service-connected disability at death or
veteran's death was the result of a service-connected condition. I request USDVA complete this certification in support of my separate
application for the Disabled Veteran's Property Tax Exclusion to the Tax Assessor.
Disabled Veteran's Signature
DISABLED VETERAN'S SIGNATURE DATE
DATE
Surviving Spouse's (who has not remarried) Signature
To be completed by the U.S. Department of Veterans Affairs
SURVIVING SPOUSE'S SIGNATURE
CITY
Property Tax Exclusion (G.S. 105-277.1C
NAME (Print or Type)
SURVIVING SPOUSE'S FULL NAME (PRINT OR TYPE)
DISABLED VETERAN'S FULL NAME (PRINT OR TYPE)
SECTION 1
State of North Carolina
U.S. DEPT. OF VETERANS AFFAIRS
FILE NUMBER
VETERAN'S SOCIAL SECURITY NUMBER
(If Applicable)
Certification for Disabled Veteran's
TO BE COMPLETED BY THE VETERAN OR THE
SURVIVING SPOUSE WHO HAS NOT REMARRIED
STREET ADDRESS OR P.O. BOX NUMBER
NOTE:
Stamped Signature by USDVA Official on this form has been
authorized by Director, VA Regional Office,
Winston-Salem, NC.
SECTION 2
SECTION 3
SECTION 4
Veteran has a service-connected permanent and total disability that existed as of_____________________ .
C.
Please
check all
that apply:
Character of Disabled Veteran's
Service at Separation: (DD-214)
NC Division of Veterans Affairs authorizes the NC Department of Revenue and any County Tax Office to use this form as needed.
