Form N-172 Claim for Tax Exemption by Person With Impaired Sight or Hearing or by Totally Disabled Person and Physician's Certification - Hawaii

Form N-172 is a Hawaii Department of Taxation form also known as the "Claim For Tax Exemption By Person With Impaired Sight Or Hearing Or By Totally Disabled Person And Physician's Certification". The latest edition of the form was released in January 1, 2018 and is available for digital filing.

Download a PDF version of the Form N-172 down below or find it on Hawaii Department of Taxation Forms website.

Step-by-step Form 172 instructions can be downloaded by clicking this link.

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Clear Form
FORM
STATE OF HAWAII — DEPARTMENT OF TAXATION
N-172
Claim for Tax Exemption by Person with Impaired
(REV. 2018)
Sight or Hearing or by Totally Disabled Person
and Physician’s Certificatio
n
(NOTE: References to “married” and “spouse” are also references to “in a civil union” and “civil union partner,” respectively.)
If you are submitting Form N-172 in response to either an adjustment letter or a collection notice, please check here
ä
Part I
Claim for tax exemption
INDIVIDUAL:
CORPORATION, PARTNERSHIP, or LLC:
Name of Individual
Name of Corporation, Partnership, or LLC
Individual’s Social Security No.
Spouse’s Social Security No.
Federal Employer I.D. No.
Street Address of Individual
Street Address
City, State & Postal/ZIP Code
City, State & Postal/ZIP Code
all of whose shareholders, partners, or members are individuals who are
(check all applicable categories)
who is (check applicable category)
A person who is blind as defined in sec. 235-1, HRS,
Blind as defined in sec. 235-1, HRS,
A person who is deaf as defined in sec. 235-1, HRS,
Deaf as defined in sec. 235-1, HRS,
A person totally disabled as defined in sec. 235-1, HRS,
Persons totally disabled as defined in sec. 235-1, HRS,
hereby claims the benefits provided under the General Excise Tax and/or Income Tax Laws. (Check all applicable categories and provide the information
requested. See separate instructions for the definitions of blind, deaf, and person totally disabled.)
General Excise Tax (sections 237-17 and 237-24(13), HRS)
(a) General Excise Hawaii Tax I.D. No. GE ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___ - ___ ___
(b) Doing Business As (DBA)
(c)
Business Address
(d) Type of Business Activity
(e) Individual’s Percentage of Ownership:
; Spouse’s percentage:
Income Tax (section 235-54, HRS) (for individuals only)
(a) Name on income tax return (if joint, show both names)
I declare, under the penalties set forth in section 231-36, HRS, that I have examined/understand the detail contents of this claim and to the best
of my knowledge and belief, it is true, correct, and complete.
IN THE CASE OF A CORPORATION, PARTNERSHIP, OR LLC, THIS FORM MUST BE SIGNED BY AN OFFICER, PARTNER OR MEMBER, OR DULY AUTHORIZED AGENT.
Taxpayer Signature (individual, corporate officer, partner or member, or duly authorized agent)
Date
Title
NOTE: DISABILITY OR IMPAIRMENT MUST BE CERTIFIED BY LICENSED PHYSICIANS,
OPTOMETRISTS, ETC., ON THE BACK OF THIS FORM.
FORM N-172
ID NO 01
N172_I 2018A 01 VID01
Clear Form
FORM
STATE OF HAWAII — DEPARTMENT OF TAXATION
N-172
Claim for Tax Exemption by Person with Impaired
(REV. 2018)
Sight or Hearing or by Totally Disabled Person
and Physician’s Certificatio
n
(NOTE: References to “married” and “spouse” are also references to “in a civil union” and “civil union partner,” respectively.)
If you are submitting Form N-172 in response to either an adjustment letter or a collection notice, please check here
ä
Part I
Claim for tax exemption
INDIVIDUAL:
CORPORATION, PARTNERSHIP, or LLC:
Name of Individual
Name of Corporation, Partnership, or LLC
Individual’s Social Security No.
Spouse’s Social Security No.
Federal Employer I.D. No.
Street Address of Individual
Street Address
City, State & Postal/ZIP Code
City, State & Postal/ZIP Code
all of whose shareholders, partners, or members are individuals who are
(check all applicable categories)
who is (check applicable category)
A person who is blind as defined in sec. 235-1, HRS,
Blind as defined in sec. 235-1, HRS,
A person who is deaf as defined in sec. 235-1, HRS,
Deaf as defined in sec. 235-1, HRS,
A person totally disabled as defined in sec. 235-1, HRS,
Persons totally disabled as defined in sec. 235-1, HRS,
hereby claims the benefits provided under the General Excise Tax and/or Income Tax Laws. (Check all applicable categories and provide the information
requested. See separate instructions for the definitions of blind, deaf, and person totally disabled.)
General Excise Tax (sections 237-17 and 237-24(13), HRS)
(a) General Excise Hawaii Tax I.D. No. GE ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___ - ___ ___
(b) Doing Business As (DBA)
(c)
Business Address
(d) Type of Business Activity
(e) Individual’s Percentage of Ownership:
; Spouse’s percentage:
Income Tax (section 235-54, HRS) (for individuals only)
(a) Name on income tax return (if joint, show both names)
I declare, under the penalties set forth in section 231-36, HRS, that I have examined/understand the detail contents of this claim and to the best
of my knowledge and belief, it is true, correct, and complete.
IN THE CASE OF A CORPORATION, PARTNERSHIP, OR LLC, THIS FORM MUST BE SIGNED BY AN OFFICER, PARTNER OR MEMBER, OR DULY AUTHORIZED AGENT.
Taxpayer Signature (individual, corporate officer, partner or member, or duly authorized agent)
Date
Title
NOTE: DISABILITY OR IMPAIRMENT MUST BE CERTIFIED BY LICENSED PHYSICIANS,
OPTOMETRISTS, ETC., ON THE BACK OF THIS FORM.
FORM N-172
ID NO 01
N172_I 2018A 01 VID01
FORM N-172
(REV. 2018)
PAGE 2
Social Security Number _________________________
Applicant’s Name ___________________________________
Part II
Physician’s or optometrist’s certification. Complete only one section, even if applicant has multiple disabilities.
This form may be rejected if the appropriate section and the certification are not fully completed. If
Section A is completed, sign authorization for release of information located at the bottom of this page.
SECTION A — EYE EXAMINATION
(Must be done by a qualified ophthalmologist or optometrist.)
1.
Diagnosis _____________________________________________________________________
2.
Vision 1) without corrective lenses:
OD: _______
OS: _______
2) with corrective lenses:
OD: _______
OS: ______
3.
Is this applicant’s visual acuity 20/200 or worse in the better eye with corrective lenses?
Yes
No
4.
Is the widest diameter of the field of vision less than 20 degrees?
Yes
No
5.
Date first certifiable as legally “blind” (MM/DD/YYYY) ___________________________________
6.
Should applicant be re-examined for tax purposes?
Yes
No
If “Yes,” when? _____________________
(Must be done by a qualified otolaryngologist; i.e., Board-certified ear,
SECTION B — HEARING EXAMINATION
nose & throat specialist, or a licensed audiologist.)
1.
Diagnosis ________________________________________________________________________________________
2.
Hearing loss (500-2000 Hertz) without aid:
Right ______________
Left _______________ (Decibels ASA or ANSI 1969)
3.
Is the applicant’s average loss in speech frequencies (500-2000 Hertz) in the better ear, 82 Decibels ASA
(or 92 Decibels ANSI 1969) or worse?
Yes
No
4.
Date first certifiable as legally “deaf”(MM/DD/YYYY) ____________________________________
5.
Should applicant be re-examined for tax purposes?
Yes
No
If “Yes,” when? _____________________
(Must be done by physicians as described in the definition for “person
SECTION C — REPORT ON DISABILITY
totally disabled” under section 235-1, Hawaii Revised Statutes.)
1.
Diagnosis ________________________________________________________________________________________
2.
Date individual came under your care ____________ Date individual first disabled or unable to work _______________
3.
Is the individual totally disabled, either physically or mentally?
Yes
No
4.
Is the disability permanent? (See “Person totally disabled” under Definitions in separate instructions.)
Yes
What is the effective date of disability? (MM/DD/YYYY) ______________________________________
No
When should individual be re-examined to determine extent of disability?(MM/DD/YYYY)_________________________
5.
Is the individual able to engage in any substantial gainful business or occupation? (See “Person totally disabled” under
   
Definitions in separate instructions.)
Yes
No
6.
Pertinent symptoms or findings that preclude the individual’s ability to engage in gainful work.
_______________________________________________________________________________________________________
CERTIFICATION BY PHYSICIAN, OPTOMETRIST, ETC.
I hereby certify that the above applicant conforms to the State definition of “Blind,” “Deaf,” or “Totally Disabled.” Sign this certification only if the applicant
meets the applicable definition.
Date of Certification
Signature of Certifying Professional
Professional License Number
Date License Expires
Print Name of Certifying Professional
State/Other Licensing Authority
Address of Certifying Professional
AUTHORIZATION FOR RELEASE OF INFORMATION BY BLIND APPLICANT
I hereby authorize the Department of Taxation, State of Hawaii, to release my name, social security number, address, information on my eye condition
and certification of my legal blindness as stated on tax Form N-172, to Ho’opono Services for the Blind Branch, Department of Human Services, State of
Hawaii. The purposes of sharing this information are to maintain a State register of persons who are legally blind as mandated by section 347-6, Hawaii
Revised Statutes, and to apprise me of services available from Ho’opono Services for the Blind.
Print Full Name of Blind Applicant
Date
Address of Blind Applicant
Signature of Blind Applicant or witnessed X. If signed X used, two
Social Security Number of Blind Applicant
witnesses must sign
Witness #1 - Signature, If X used.
Witness #2 - Signature, If X used.

Download Form N-172 Claim for Tax Exemption by Person With Impaired Sight or Hearing or by Totally Disabled Person and Physician's Certification - Hawaii

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