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Robert S. Wertz, Jr. Web loudoun.gov/COR Phone [PHONE REDACTED] Mailing Address PO Box 8000, Leesburg, VA 20177-9804 In-person Service Leesburg - 1 Harrison Street SE, 1st Floor Sterling - 46000 Center Oak Plaza Disability Affidavit for Tax Relief Applicant: Authorization to Disclose Health Information I, of in Loudoun County, Virginia, Applicant's Full Legal Name (Print) Applicant's Street Address voluntarily consent and authorize to disclose my individually Licensed Medical Provider Name identifiable health information to the Loudoun County Commissioner of the Revenue's Office as part of my application to the County's Tax Relief Program. Applicant Signature Date Signed Licensed Medical Provider: Affidavit - Sign before a Notary Public The Code of Virginia 58.1-3217 states: "Permanently and totally disabled shall mean unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment or deformity which can be expected to result in death or can be expected to last for the duration of such person's life." I, swear or affirm that I am a medical doctor licensed to Provider's Full Legal Name Provider's Credentials practice in the Commonwealth of Virginia or am practicing medicine as an active duty military officer. On Date I either [ ] thoroughly examined or [ ] completed review of the medical file of Name of Patient/Applicant and I found them to have a medically determinable physical and/or mental disability since which Date Disability Began prevents substantial gainful activity and is expected to result in their death or last for the duration of their life. I have read the portion of Virginia law provided above and I find this patient's medical condition(s) to be totally disabling and permanent in nature. Signature Date Provider Street Address City Zip Notary Public - In the Commonwealth of Virginia, City/County of I certify that the above-named person, being first identified and duly sworn by me, affirmed that the statements given are true and correct. Subscribed and acknowledged before me on this day of 20 Notary Public Registration No. Commission Expires SEAL 1 I TED24-1225 SIGN SIGN ---PAGE BREAK--- Disability Affidavit for Tax Relief General Information Use this form for disability verification by a medical provider, if applicable, and submit when the applicant is applying for Real Estate and/or Vehicle Tax Relief. When seeking tax relief through Loudoun County, applicants may verify that they meet the criteria in Virginia law for having a "permanent and total disability" in one of four ways. These include providing disability certification from the Social Security Administration, the Department of Veterans Affairs, the Railroad Retirement Board, or, by providing sworn affidavits from two medical doctors licensed in Virginia or two military officers who practice medicine in the U.S. Armed Forces. If choosing to submit sworn affidavits, this form should be used for each practitioner. At least one of these practitioners must have examined the applicant while the other may have examined the applicant's medical record(s). Review relevant info at loudoun.gov/TaxRelief-Older-Disabled. You can find online forms at loudoun.gov/COR-Forms. Need help? Staff assistance is available Monday through Friday, during County business hours. To reduce your wait time, we encourage scheduling an appointment. We are open 8:30 AM to 5:00 PM in: Leesburg 1 Harrison St. SE, 1st Floor Sterling 46000 Center Oak Plaza For assistance with a specific topic, email or call: Residential Real Estate [EMAIL REDACTED] [PHONE REDACTED], option 3 Tax Relief, Exemptions & Deferrals [EMAIL REDACTED] [PHONE REDACTED] Vehicle Personal Property [EMAIL REDACTED] [PHONE REDACTED], option 1 Accommodations: To request language assistance or a reasonable accommodation for any type of disability to access this form, please contact [EMAIL REDACTED] or [PHONE REDACTED]/TTY-711. Advance notice is requested. Privacy: This Office protects records according to applicable Virginia statutes and U.S. federal laws. Any personal information we collect and maintain is retained in compliance with statute. Instructions 1. Authorization to Disclose Health Information - The tax relief applicant completes this section, authorizing their healthcare provider to complete the affidavit. 2. A˜davit- The Virginia-licensed medical doctor or active duty military officer who practices medicine with the U.S. Armed Forces completes this section and signs before a notary to verify that the applicant has a permanent and total disability, according to the definition in Virginia law. 3. Submit this form in-person at one of the locations listed above or: Mail it to: Loudoun County Commissioner of the Revenue Attn: Tax Exemptions & Deferrals PO Box 8000, Leesburg, VA 20177-9804 2 I Loudoun County I Office of the Commissioner of the Revenue I TED24-1225