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.�,-,. � Physician's Certification of Disability FORM �Ne`,•rar.•ka( partmentpf for Homestead Exemption /�Gp �r��:��G The disability must have occurred prior to January 1 of the application year, `tJp B Applican •� e County ��_� �. ��-�, Address I ` ° ��l�� rit��m}�e�� �l ��. C� / State 7ip Code Veteran's Service�ates � _ w � � Beginniny _,_ and Ending___. —�--- °-- - _ �---...� EX�MPTIONS FOR QUALIFIEC VE i cRANS 1 ❑ Exeznption for a erar�tota.11y di led due to non-s z� icc cor z1 c ed illziess(azznual certificatioi�required). � 2 ❑ �x.emption for a e eran totally di led duTe to n�n-s ice co ected accident:(annual certification required). -- __.. __. ___ _._.__ __.._ .._.�.�._ [XEMPTIONS�pR QUALIFI�D INDIVIDUALS __ .. _.._ __ _,. - _.. .,.._. � _ _._�__ .,..... ...� 3 0 Fxcinption for an individual wha has a permaneni:phytiical disability and has lost xll mobility lhat precludes locoinotion wilhol.it thc regular use of a mechanical aid orprosthesis. 4 ❑ Fxc�mption for an individual who has pe�rinaneait partial disabrlity of�both anns in excess of 75�%,_ 5 �] Gxet�lption for'an indavidua] who lias undea'gone ampul.atinn of both arms above thc e]bow. fi �� 1'his applicant does NU'1�rneei�ny nf tl�c cxen�pt.ions lrsted above. -�-- .___ ---- __ _ _ . _-- _�`�� y - - I hereby certifv?hat I f dvr-.examinn.d?h�a�� c�n ��ar-�ed al,��ve Gnd tr,tt-besi of ir,,,kn�P � he or she has the disal�ilit descnbed and indicaicd above;nr StatemPnt 6 is irue as indicat�d. �� sNgn � ��d� _� �► .. _-�}-}�...� __ �/ �-.. `� .-- -? -�r-._. -- here Signature of Qualified Medical Practitio`ner JUt_ 1�' Date _.... �__ / 1'L!°��/��/l.� �/ ' . -�.�-��[�U�1TY WS.��AS(.`k,V, Te��neNum�r -�� ... • F 3 l� Printed Name of 4ualified Medical Pr-�tioner i. ---- GRAND 15LAND,N� exem tionulaw5 to the`�ned�ral pra�titioner tn disclose __ _..,. �.,.__. � Y - . any of the medical intnrmation ner,essary tor con�pliance with the Nehraska hiorriestead P " " �rl/ __C;ounty Assessnr and the Nebraska�epartrnent of Revenue � . � .��g� _��Pi1.ra.+._ � /f� ? � — �'; - -- �.�-�-"��.---- _ ._ _. _....— � ' �i.... -- — 1.,,�y�e �SigriatureU�'Applicahi , fJate �� fl ii�STFUCTIONS WH� MAY FILE. • /1ny wa�l.imc veteran,di�char'�.ed or otherwi�c separated wit.h a characterizaiion of)aonorable or gene�°al dischar�e (under honorable conditions) and who on January ] is total]y disabled as dcscrihed in 1 nr 2 above: ot• • An individual who on lanuary 1 inccts any of'lhe disability rcquri-errzents in 3,4, or S above. DEFINI7NONS. "Mcchanrcal aid" means � devi�e or apparatus Such as a brace, c:rutch, canc_ or whccichair. "Prost.hcsis" rracans a device t}7,11 rJC'I771fiI7E11T�ji or ternporarily rcplaces a missirag part or a nont'unctinning pari nf the. t,u�z��t,�,�iy_ "Qualified tnedical practitioner"means a physician,physician assista�zt., or advattccd practice registcred n:urse. WHEN AND WH�R�70 FILE.The onginal of this certification inust he aitached to the NeUx-aska Hoa��cstead Exemption AppNcal.ion nr Cert:ification of Status,Fo��qSS_and f led after l�ebruary] and oa�nr beiorc June 30 with your cou��ty assessor. Ce�-tification for a veteraai totally dasahled by a��on-servicc connected accident or illness must be filed annually. SIGNi4Tl1RE.'This for��l must be si�ned by a qualificd iriedical practitioner as defined abowe.This fortzl iriust he signcd hy the applic;ant to authorize il�c quali�ied medica]practitiotaer to disclosc health infor��laiion to thc county assessor. Any indication that a change has been made to the criginal completed certification may result in the homestead exemptian appiication being denied. �...___ ..._ .. �.... _.__ _. _ ..-- Ne6r;�ska pepanment of Revenue Forrn Number �Authorized by Neb.Aev.Stat.§77�3508 96-294•?p09 Rev.i-201�Supersedes 96�294-2D09 CONTAC7YDUR COUNTY ASSESSpR FOR ANY QUESTIDNS REGARDING 7HIS FORM. RE7AIN A COPY FpR YbUR R�CORDS,