FIRST RESPONDER’S
PHYSICIAN CERTIFICATE OF
TOTAL AND PERMANENT DISABILITY
Section 196.102, Florida Statutes
I, , a physician licensed pursuant to chapter 458 or
Physician’s name
chapter 459, Florida Statutes, hereby certify that Mr. Mrs. Miss Ms.
Applicant name
Social Security Number* - - , is totally and permanently disabled due to an impairment
of the mind or body, and such impairment renders him or her unable to engage in any substantial
gainful occupation, which condition is reasonably certain to continue throughout his or her life.
Mr. Mrs. Miss Ms. has the following mental or physical
condition(s):
It is my professional belief that within a reasonable degree of medical certainty, the above-named
condition(s) render Mr. Mrs. Miss Ms. _____________________________________
Name of totally and permanently disabled person
totally and permanently disabled and that the foregoing statements are true, correct, and complete to
the best of my knowledge and professional belief.
___________________________________________ ________
Signature Date
Address: (print)
Street City State Zip
Florida Board of Medicine or Osteopathic Medicine license number
Issued on .
NOTICE TO TAXPAYER: Each Florida resident applying for an exemption due to a total and permanent disability that
occurred in the line of duty while serving as a first responder must present to the county property appraiser the required
physician certificate(s), the required documentation from the Social Security Administration, and a certificate from the
employer for whom the applicant worked as a first responder at the time of the injury or injuries, as required by section
196.102(5), Florida Statutes. This form is to be completed by a licensed Florida physician.
NOTICE TO TAXPAYER AND PHYSICIAN: Section 196.102(10), Florida Statutes, provides that any person who knowingly
and willingly gives false information for the purpose of claiming the homestead exemption for totally and permanently
disabled first responders commits a misdemeanor of the first degree, punishable by a term of imprisonment not exceeding 1
year or a fine not exceeding $5,000, or both.
*Disclosure of your social security number is mandatory. It is required by section 196.011(1), Florida Statutes. The social
security number will be used to verify taxpayer identity information and homestead exemption information submitted to
property appraisers.
