Disabled Low-Income Utility Tax Exemption Form - City of Norwalk
Disabled Low-Income Utility Tax Exemption Form - City of Norwalk
Disabled Low-Income Utility Tax Exemption Form - City of Norwalk
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Other: (Specify medical disorder and resultant restrictions <strong>of</strong> mobility.)Certification:I hereby certify that I am a licensed physician <strong>of</strong> the State <strong>of</strong> California and have knowledge <strong>of</strong> theabove applicant. I have completed this application by checking all applicable disabilities andrecommend that the <strong>City</strong> <strong>of</strong> <strong>Norwalk</strong> issue the <strong>Utility</strong> User’s <strong>Tax</strong> <strong>Exemption</strong> to the applicant on thefollowing basis:Temporary disability (minimum <strong>of</strong> three months)Estimated period <strong>of</strong> disability _______________Permanent disability_______________________Physician’s Signature____________________DateUpdated 7/03 Page 4
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