Form 82514B Fillable Certification of Disability for Property Tax Exemption
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

(City) (State) (Zip) (Street) (Type or Print) (Last) (First) (Initial) Address: Business Address City State Zip Date of Birth: Marital Status: Single Married Physician or Psychiatrist s Name Telephone Number 1 A R S Title 32 Chapter 8 13 14 17 19 1 or 29; or 1 Last for a continuous period of 12 months or more or 2 Result in death within 12 months 2 The laws of another state that are comparable to the laws governing persons qualifying under subsection (B)(1) A For purposes of the property tax exemption in the Arizona Constitution Article 9 Section 2 2 a person is totally and and permanently disabled as defined above YES NO any physical or mental impairment that is expected to: Applicant s Name: Applicant s Signature: Date Signed: Article 4 42 11151 42 11152 42 11153 and Arizona Administrative Code R15 4 116 B To qualify for the exemption a disabled person shall be certified as totally and permanently disabled by a person licensed CERTIFICATION OF DISABILITY FOR PROPERTY TAX EXEMPTION DOR 82514B (12/2011) exemption affidavit (DOR 82514) is processed for the current Tax Year if hand delivered the copy of this form which has I hereby certify the applicant s condition as stated below: MEDICAL CERTIFICATION FOR TOTALLY AND PERMANENTLY DISABLED PERSONS of Individual Exemption form with the County Assessor of the county in which the applicant s property is located no later permanently disabled if the person is unable to engage in any substantial gainful activity for pay or profit by reason of Physician or Psychiatrist s Signature Date Physician s or Psychiatrist s Office Stamp: postmarked on or before the last business day of February Pursuant to Arizona Administrative Code R15 4 116: Exemption for Totally and Permanently Disabled Person Pursuant to Article IX Sections 2 2 1 2 2 and 2 3 of the Arizona Constitution A R S Title 42 Chapter 11 Article 3 42 11111 and than the last business day in February If this form and the DOR 82514 are mailed to the County Assessor they must be The above named applicant is unable to engage in any substantial gainful activity and therefore is considered to be totally the applicant s and the physician s or psychiatrist s signatures MUST be filed along with the copy of the DOR 82514 Affidavit THE FOLLOWING IS TO BE COMPLETED BY THE EXAMINING PHYSICIAN OR PSYCHIATRIST: This form can be completed on line and then printed or it can be printed and completed manually To assure that the Type or Print under: