Form Schedule DIS Certificate of Disability

YES NO (Rev 8/12) CERTIFICATE OF DISABILITY 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 2012? ADDRESS BUSINESS ADDRESS CERTIFICATION OF PHYSICIAN City State Zip Code I certify that I have personally examined the physical and mental condition of the above named individual If you are claiming homestead benefits 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 certification of disability letter that shows you are receiving benefits based upon a total and permanent disability which prevented you from being engaged in any substantial gainful activity during the entire calendar year of 2012 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 2012 must not exceed the limits set by the Social Security Administration for 2012: $12 120 if the impairment is other than blindness; $20 280 if the individual is blind KANSAS 2012 NAME OF PERSON EXAMINED Nature of disability Page 15 PHONE DATE PHYSICIAN S NAME Please type or print Schedule SIGNATURE OF PHYSICIAN SOCIAL SECURITY NUMBER Street or RR Street or RR (Include apartment number or lot number) When was the condition originally diagnosed?