GREGORY J. SMITH SAN DIEGO COUNTY ASSESSOR 1600 PACIFIC HIGHWAY, ROOM 103 SAN DIEGO, CALIFORNIA 92101-2480 TELEPHONE: (858) 505-6262 CERTIFICATE OF DISABILITY The patient listed below has applied to transfer their property tax base to a replacement property. In order to qualify for this one time exclusion, a licensed physician or surgeon must certify that the disability is both severe and permanent. The definition for a severely and permanently disabled person is: any person who has a physical disability or impairment, whether from birth or reason of accident or disease, including, but not limited to, any disability or impairment which affects sight, speech, hearing, or the use of any limbs and which results in a functional limitation as to employment or substantially limits one or more major life activity of that person, and which has been diagnosed as permanently affecting the person's ability to function. TO BE COMPLETED BY PHYSICIAN Patient's Name _________ __________ Patient's S.S.N. Type of Disability (please describe in detail) _ _________________________________________________________________ Why does the disability necessitate the move and how will the move alleviate the disability? _ _ ____________________________________________________________________________________ I Certify that in my medical opinion the above named patient does qualify as a disabled person according to the definition above. Physician's Signature _ _ Physician's Name (printed or typed) Date __________ (____ )_____ Physician's Phone TO BE COMPLETED BY APPLICANT, APPLICANT'S SPOUSE OR LEGAL GUARDIAN The applicant must state in their own words that either: A) The replacement dwelling meets the disability-related requirements identified above and that the primary reason for the move to the replacement dwelling is to satisfy those requirements, OR B) The primary reason for the move is to alleviate financial burdens caused by the disability. _________________________________________________________________________ I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. SIGNATURE(S) ____________ Date ____ _ 110CERT.FRM(REV.06/99) American LegalNet, Inc. www.USCourtForms.com