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BOE‑19‑DC (P1) REV. 00 (02‑21) CERTIFICATE OF DISABILITY The claimant listed below has applied to transfer their property tax base to a replacement primary residence. In order to qualify for this tax benefit, a licensed physician or surgeon of appropriate specialty must certify that the disability of the claimant, or claimant’s spouse, is severe. The definition of a severely disabled person is any person having a great degree of impairment or who is greatly limited by a physical, mental, cognitive, or developmental condition. I. TO BE COMPLETED BY A PHYSICIAN (please print) Description of patient’s disability: Patient’s name: Date of disability: Identify: the specific reasons why the disability necessitates a move to the replacement primary residence and the disability‑related requirements, including any locational requirements, of a replacement primary residence: I am a licensed physician surgeon. My specialty is: CERTIFICATION OF DISABILITY I certify that in my medical opinion, the above-named patient does qualify as a disabled person according to the definition above. SIgnATuRE OF PHYSICIAn OR SuRgEOn DATE PHYSICIAn OR SuRgEOn’S nAME (print or type) DAYTIME PHOnE nuMBER ( II. TO BE COMPLETED BY CLAIMANT, CLAIMANT’S SPOUSE OR LEGAL GUARDIAN (please print) nAME OF CLAIMAnT nAME OF SPOuSE OR LEgAL guARDIAn PROPERTY ADDRESS ASSESSOR’S PARCEL/ID nuMBER CERTIFICATE OF DISABILITY-RELATED REQUIREMENTS (check A or B) A: 1. The claimant, spouse, or legal guardian must describe how the replacement primary residence meets the disability‑related requirements identified in Part I (Part I must be completed by a physician or surgeon): AND 2. I certify (or declare) under penalty of perjury under the laws of the State of California that the primary purpose of the move to the replacement primary residence is to satisfy the identified disability‑related requirements described in Part I. OR B: I certify (or declare) under penalty of perjury under the laws of the State of California that the primary purpose of the move to the replacement primary residence is to alleviate the financial burdens caused by the disability. Please explain: SIgnATuRE OF CLAIMAnT, SPOuSE, OR LEgAL guARDIAn PRInTED nAME DAYTIME PHOnE nuMBER ( ) DATE EMAIL ADDRESS t t daytime THIS DOCUMENT IS NOT SUBJECT TO PUBLIC INSPECTION Donald O'Connor Alpine County Assessor/Recorder PO Box 155 Markleeville, CA 96120 Ph: (530) 694-2283