DTE 105E Rev. 2/16 Certificate of Disability for the Homestead Exemption Attach this form to the homestead exemption application (form DTE 105A) if the applicant is requesting the homestead exemption based on disability status. Ohio Revised Code section 323.151: " `Permanently and totally disabled' means a person who has, on the first day of January of the year of application for reduction in real estate taxes, some impairment in body or mind that makes the person unable to work at any substantially remunerative employment that the person is reasonably able to perform and that will, with reasonable probability, continue for an indefinite period of at least twelve months without any present indication of recovery therefrom or has been certified as permanently and totally disabled by a state or federal agency having the function of so classifying persons." To be completed by the applicant Applicant's name Home address To be completed by the physician, psychologist or state or federal agency representative. In accordance with the above, I (we) hereby certify that Name of applicant and is now permanently and totally disabled according to the above definition by virtue of physical disability or mental disability. License number and state issuing (Note: If reason for reduction is mental disability, the physician or psychologist must hold an Ohio license.) was, as of Jan. 1, , Physician (signature) Print name of person signing form Psychologist (signature) Address (please print) Agency (please print) City State ZIP code If agency, signature and title of person completing the form Date In lieu of having a physician or psychologist sign this form, the applicant may submit a statement from an eligible state or federal agency that the applicant is permanently and totally disabled as defined above. See the back page of this form for more information on what constitutes acceptable proof of permanent disability. American LegalNet, Inc. www.FormsWorkFlow.com Acceptable and Unacceptable Proofs of Permanent and Total Disability Physician's Certificate: Acceptable. An application based on physical disability must include a certificate signed by a physician. An application based on mental disability must include a certificate signed by a physician or a psychologist licensed to practice in Ohio. Note: A chiropractor is not a "physician" for purposes of the Homestead Law. Federal Agencies: Social Security Administration (SSA): An SSA (or SSI) form indicating that an applicant is "disabled" is acceptable. The SSA only gives disability benefits to those who are permanently and totally disabled. Department of Veterans Affairs (VA): Veterans with a total service-connected disability or veterans who are receiving 100% compensation for service-connected disabilities following a determination of individual unemployability should file DTE form 105I and submit the documentation indicated by that application. If a veteran does not qualify as an eligible disabled veteran, but meets the definition found in R.C. 323.151(D) (provided at the top of this form), the veteran must have a doctor or qualifying psychologist complete this form. No VA documentation reflects the statutory definition of permanent and total disability in R.C. 323.151(D). Railroad Retirement Board (RRB): The RRB has two types of disability pensions: (1) total and permanent disability and (2) occupational disability. Only the "permanent and total disability" pension is acceptable. State Agencies: Bureau of Workers Compensation: A determination of "permanent and total disability" is acceptable. Other determinations, such as "permanent and partial disability" "temporary and total disability," and "temporary and partial disability" are not. State Retirement Systems: Not acceptable. The Public Employees Retirement System (PERS), the State Teachers Retirement System and the School Employees Retirement System (SERS), do not certify permanent and total disability. While the State Highway Patrol Retirement System (HPRS) and the Police and Firemen's Disability and Pension Fund (PFDPF) do certify individuals to be "permanently and totally disabled" these determinations are job-specific and do not rule out the possibility of other substantially remunerative employment using a different set of skills. American LegalNet, Inc. www.FormsWorkFlow.com