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^--- Certification of Disability for Homestead Exemption FORM Nebraska Department of •The disability must have occurred prior to January 1 of the application year. REVENUE o �/t (/t� g•See instructions co reverse side. (///fit 458 B APnel ir� s Li Qi�4-J County 'yI^i//'/t 1/AO Address ? F, ��rn� Vl�,S o 57/ • (/ .fate 't• r Zip Code Veterans Service Dates \V[ 4 s' Beginning and Ending . Disability Certification for Qualified Veterans 1 ❑ Veteran totally disabled due to non-service connected illness(annual certification required). 2 ❑ Veteran totally disabled due to non-service connected accident(annual certification required). . Disability Certification for Qualified Individuals 3 ( Individual with a permanent physical disability who has lost all mobility that precludes locomotion without the regular use of a mechanical aid or prosthesis. ,__ ,r/ 4 ❑ Individual with a permanent partial disability of both antis in excess of 75%. 5 ❑ Individual who has undergone amputation of both anus above the elbow. 6 ❑ This applicant does NOT meet any of the exemptions listed above. I hereby certify that I have examined the applicant named above,and to the best of my knowledge and belief,he or she has the disability described and indicated above;or line 6 is true as indicated. sign hut here Signature ofQualilled Licensed i edical Pra I•ner o P.O.Box 2939 Primed Name of Qualified Lice .! Medical Practitioner Phone Numbpt�A sa„"ui a266 Fan(:306.362-5299 Address City State Zip Code I Developmental Disability Certification for Qualified Individuals I 7 ❑ Individual who has a developmental disability. It has been determined that the applicant named above is eligible for developmental disabilities services and has a developmental disability as defined in Neb.Rev.Stat.§83-1206. sign here ■Signature of Deputy Director,Division of Developmental Disabilities,Department of Health and Human Services Date Printed Name of Deputy Director,Division of Developmental Disabilities,Department of Health and Human Services Phone Number 1; IN do x r. tai) ACC JUL 2 7 2015 ` , iFr“J. nj V uri,�d I h ebyauthori :this mad' -1 prat tiorpm or•_- i - �y r J'DHHS o disclose any of the medical Information necessary for complian�444i he •br--ka hem- lead exe :we the 1kS-_ 1 • my Assessor and the Nebraska Department of Revenue. Sign I (0.• , Fi• )/- 16 he 3 gn. u - Applicant Date . ._.... - Authorized by Neb.Rev.Stat.§77-0508 Nebraska Department of Revenue Form Number - 9 96-294-2009 Rev.1-2015 Supersedes 96-294£009 Rev.1-2014 Contact your county assessor for any questions regarding this form. Retain a copy for your records.