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taxmap/instr/i1040sr-003.htm#TXMP4c8d7c23

Instructions for Physician's Statement(p4)


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taxmap/instr/i1040sr-003.htm#TXMP04760263

Taxpayer(p4)


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If you retired after 1976, enter the date you retired in the space provided on the statement below.
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Physician(p4)


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A person is permanently and totally disabled if both of the following apply.
  1. He or she cannot engage in any substantial gainful activity because of a physical or mental condition.
  2. A physician determines that the disability has lasted or can be expected to last continuously for at least a year or can lead to death.

Physician's Statement

 I certify that                                                                                          
   Name of disabled person 
was permanently and totally disabled on January 1, 1976, or January 1, 1977, or was permanently and totally disabled on the
date he or she retired. If retired after 1976, enter the date retired.  ▸                              
Physician: Sign your name on either line A or B below.
AThe disability has lasted or can be expected to last continuously for at least a year             
   Physician's signatureDate
BThere is no reasonable probability that the disabled condition will ever improve             
   Physician's signatureDate
Physician's name Physician's address 
    
  
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