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

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.

	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.
A	The disability has lasted or can be expected to last continuously for at least a year
		Physician's signature	Date
B	There is no reasonable probability that the disabled condition will ever improve
		Physician's signature	Date
Physician's name		Physician's address