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ORAINGE COl91d'1'"t ASSF.5.St3R'S 01=1+1C <br />Form AV•9A ~,a ~,~`~;~* P.O. BOX 81$1 <br />p:a~. i-~a~ ~ HILLSBOROUGH, NORTH CAROLINA 27; <br />~ ~ . <br />. nN <br />STATE OF NORTH CAROLINA <br />CERTIFICATION OF DISABILITY UNDER N.C.G,S. §105-277.1 FOR PARTIAL AD VALOREM <br />TAX EXCLUSION <br />~axnayer / Annlicatit~nfQrmatiun <br />Name: ~~ ~~ <br />t.,,se Fuse ~ M_I, <br />Address: ~ ~ ~ ~, ~ ~ ~ ~~ / ~ -~ <br />~~i ~ ~ ~~ w~ ~~ ~ ~-~~~ <br />Telephone: (~,~T) ___ ~ '~ ~ <br />This section is to be completed o-niv by a physician licensed to practice medicine in the~.State of <br />North Carolina or from a governmental agency which is authorized to determine qualification <br />fo~• disability benefits. This document serves as.:~n oflicial certification as described in §105- <br />D ~ iTl' N• <br />§ 105-277.1(bl(41 Totally, and. permanently disabled - A person is totally and permanently disabled if the <br />person has a physical or mental impairment that substantially precludes him or her from obtaining <br />gainful employment and appears reasonably certain to continue without substantial improvement <br />throughout his or her life. <br />Note that because someone receives disability benefits does oat necessarily mean they qualify as <br />"totally and permanently disabled". <br />~~ -, ~~ ~ <br />I do hereby afTirm that I am qualified to determine that ~ -rc.--~ ,.~'~ <br />meets the definition of "totally and permanently disabled" which is defined ~ ove end in North <br />C.~ralina General Statute §105-277.1(b)(4). <br />,ri_ <br />i_ . ;~-....._._ ~ .. ~_ W. <br />Title ~y.+~ <br />Date ,f~"'~ " "f <br />Telephone ~ , ~' ~f i , ; _ ~ '.; :,',- ~~~ <br />