The IRS form 9400 is an annual report that certain tax-exempt organizations must file to report their unrelated business taxable income (UBTI). This document is used to calculate the amount of tax owed on any income that was generated from sources other than the organization's main exempt purpose. UBTI can be generated from a wide range of activities, so it's important for exempt organizations to understand when and how they're liable for taxes on this income. Use this guide to learn more about the IRS form 9400 and what you need to do in order to file it correctly.
| Question | Answer |
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| Form Name | Form 9400 544 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | casted, prostheses, spirometry, subd |
State of Wisconsin |
Class B Disability Permit Application |
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Department of Natural Resources |
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Form |
Page 1 of 3 |
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dnr.wi.gov |
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NOTE: If you possess a Class A or C disabled permit, you do not need to complete this application to hunt with a crossbow. Those permits allow hunting with a crossbow. [Certain Class B temporary permits also allow use of crossbow.]
Notice: Use of this form is required by the Department for any application filed pursuant to s. 29.193, Wis. Stats. The Department will not consider your application unless you complete and submit this application form. Personally identifiable information provided may be used to determine identity of the applicant, participation in natural resources surveys, eligibility for approvals, other enforcement purposes and may be provided to requesters as required by Wisconsin's Open Records law (ss.
Leave
Permit Number |
Date Issued |
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Expiration Date |
Issued By |
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Customer ID Number |
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Application must be filled out completely.
Section I – To be Completed by Applicant (Please type or print legibly)
Applicant Name |
Driver's License Number |
DNR Customer ID Number |
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Street or Route
Phone Number (incl. area code)
City, State, ZIP Code
County of Residence
Date of Birth (Mo. - Day - Year)
Color Eyes
Color Hair
Weight
Height
Sex
Male
Female
I hereby certify that the above information is true and correct, and I hereby authorize the Department of Natural Resources to examine all medical records regarding my physical disability.
Applicant Signature
Date Signed
Section II – To be Completed by Licensed Physician or Chiropractor
CLASS B PERMIT DISABILITY:
A. TEMPORARY LOWER EXTREMITY DISABILITY
Does applicant have a temporary disability which restricts mobility or ambulation due to injury or operative procedures? AND
Yes
No
a.Does applicant have a leg, hip or back, or any part thereof, casted by a licensed physician due to a fracture? OR
b.Has applicant had leg, hip or back surgery which continues to restrict mobility or ambulation? If yes, when:
Yes
Yes
No
No
B. TEMPORARY UPPER EXTREMITY DISABILITY
Does applicant have a temporary substantial loss of function or range of motion in one or both arms, or in one or both hands, or one or both shoulders, and fail to meet the minimum standards of any one of the following standard tests, administered under the direction of a licensed physician or chiropractor? Applications submitted under this paragraph need additional documentation to obtain approval (see next page).
a. Upper extremity pinch |
b. Grip |
c . |
Yes
No
C. OTHER DISABILITY OR CONDITION
Does applicant have a temporary/permanent disability or condition that precludes him/her from hunting using |
Yes |
No |
traditional methods because of valid medical reasons that restrict mobility or ambulation? If Yes, please describe the condition/disability below, in lay terms.
Physician or chiropractor use this space to explain disability in laymen terms. Use additional sheets if necessary.
Based on conclusions drawn from your knowledge/examination of the applicant's condition, which hunting or fishing method(s) does the applicant require?
For what length of time should this permit be issued? |
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1 Year |
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2 Years |
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3 Years |
If less than one year indicate length of time _____________________________________________________
Note: Permits issued for one year or more will expire on March 31st of the year of expiration.
4 Years
5 Years
Name of Physician or Chiropractor (Please Print) |
Medical License Number |
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Date Signed |
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Signature of Physician or Chiropractor |
Phone Number (include area code) |
Fax Number (include area code) |
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Address |
Mail Application To: |
Department of Natural Resources |
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Disabled Permit Applications - CS 1 |
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City, State, ZIP Code |
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PO Box 7924 |
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Madison, WI 53707 |
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(please allow 6 weeks for review and processing) |
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Class B Disability Permit Application
Form |
Page 2 of 3 |
Note to Applicant: This page is only required if you are applying for a permit to hunt with a crossbow or fish or troll with an electric trolling motor due to a temporary disability associated with muscle weakness or limited range of motion.
1.If the extent of your disability has never been measured or tested, your physician will need to direct the administration of the testing procedures indicated below. The results will need to be attached to this application.
2.Previous test results may be used for documentation if your physician or chiropractor is willing to attach those results to this application along with a statement that the attached test results are indicative of your present condition.
Registered Occupational and Physical Therapists are licensed to conduct exams for muscle and range of motion disabilities. The therapist, ON ORDERS from a physician, will conduct a test of the area of the body that you feel restricts your use of conventional archery or fishing equipment because of muscle weakness or limited range of motion.
Testing Procedures
Note to Examiner: You may use any medically accepted standard testing procedures to examine for muscle weakness or range of motion limitations of the shoulder. You should ascertain from the applicant or physician which muscle group is the source of the disability. Pain or lack of endurance alone cannot be used as grounds for granting a crossbow or electric trolling motor permit. Loss of function of the arm or hand must be substantiated through use of the standard upper extremity pinch, grip and
If muscle strength tests are scored using the scoring grades "normal" through "zero", scores at "fair" or below are sufficient proof to grant the permit. If tests are scored using the "5" through "0" scoring grades, a score of 3 or less is sufficient proof to grant the permit. If tests are used using "functional" scoring grades, scores of "nonfunctional" or less is sufficient proof to grant the permit. If the range of motion disability is less than 50% of full range, the permit can be granted.
If the applicant is being tested for a "coordinative" disability and is given the "nine (9) hole peg test" and the score falls below the
If age and sex adjusted percentile scoring tables are used (such as the grip or pinch tests), scores falling under the 10th percentile are sufficient proof to grant the crossbow hunting permit. If the "Mathiowetz" scoring tables are used, scores falling below 55% of the age and sex adjusted mean scores are sufficient proof to grant the permit.
Attach a copy of your testing protocol and results and check the appropriate box below. Permit cannot be approved without results attached to this application.
Occupational or Physical Therapist Certification
BASED ON THE EXAMINATION CONDUCTED,
The applicant IS eligible for a permit to:
The applicant is NOT eligible for a permit to:
Occupational or physical therapist use this space to explain disability in laymen terms. Use additional sheets if necessary.
Examiner Signature |
Examiner Title |
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Examiner Phone Number (include area code) |
Date Signed |
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29.193 Approvals for disabled persons. (1) TROLLING PERMITS. (a) The department shall, after an investigation and without charging a fee, issue a trolling permit to any person who meets the requirements under s. 29.171(3)(a) 2. or 4. [s. 29.171(4) (a)
2.or 4.]
(b)A person holding a current fishing license issued under this chapter and either a trolling permit issued under par. (a) or a Class A permit issued under sub. (2) may fish or troll in the waters of this state using an electric motor, notwithstanding any ordinances enacted under s. 30.77(3) that prohibit the use of motor boats on navigable waters and subject to rules promulgated by the department regarding the use of electric motors for fishing or trolling by disabled persons.
(2)HUNTING PERMITS. (a) Definitions. As used in this subsection:
1."Accompanied" means being subject to continuous visual or voice contact without the aid of any mechanical or electronic amplifying device other than a hearing aid.
5."Visually handicapped" means blind, as defined in s. 47.01(1).
(b)Issuance of permit. 1. The department shall, after investigation and without charging a fee, except for the costs of review in par. (c) 3. or (e), issue a Class A, Class B or Class C permit to any person, as provided in this subsection.
2.An applicant shall submit an application on a form prepared and furnished by the department, which shall include a written statement or report prepared and signed by a licensed physician or licensed chiropractor, prepared no more than 6 months preceding the application and verifying that the applicant is physically disabled.
3.As part of the application for a Class A or Class B permit under this subsection, the applicant shall authorize the department by written release to examine all medical records regarding the applicant's physical disability.
(c)Eligibility. 1. The department shall issue a Class A permit under this subsection to an applicant who is permanently disabled, as determined by the department, in any of the following ways:
a.Has a permanent or irreversible physical disability, is unable to ambulate and requires a wheelchair, walker, one leg brace or external prosthesis above the knee, 2 leg braces or external prostheses below the knees, 2 crutches or 2 canes for mobility.
b.Suffers significantly from lung disease, to the extent that forced expiratory volume for one second when measured by spirometry is less than one liter or the arterial oxygen tension is less than 60 millimeters of mercury on room air at rest.
c.Suffers significantly from cardiovascular disease, to the extent that functional limitations are classified in severity as class 3 or 4, according to standards accepted by the American heart association on May 3, 1988, and where ordinary physical activity causes discomfort, fatigue, palpitation, dyspnea or anginal pain.
2.The department shall issue a Class B permit under this subsection to an applicant who has a temporary disability which restricts mobility or ambulation due to injury or operative procedures and who either has a leg, hip or back, or any part thereof, casted by a licensed physician due to a fracture or has leg, hip or back surgery.
2m. The department may issue a Class B permit under this subsection to an applicant who has a temporary disability which restricts mobility or ambulation due to illness, injury or operative procedures.
Class B Disability Permit Application
Form |
Page 3 of 3 |
3.The department may issue a Class B permit to an applicant who is ineligible for a permit under subd. 1., 2. or 2m. or who is denied a permit under subd. 1., 2. or 2m. if, upon review and after considering the physical condition of the applicant and the recommendation of a licensed physician or licensed chiropractor selected by the applicant from a list of licensed physicians and licensed chiropractors compiled by the department, the department finds that issuance of a permit complies with the intent of this subsection. The use of this review procedure is discretionary with the department and all costs of the review procedure shall be paid by the applicant.
4.The department shall issue a Class C permit to any person who is visually handicapped.
(cg) Approval required. In order to hunt, fish or troll after receiving a permit under this section, the permit holder must apply for and be issued, or must already hold, any type of approval required under this chapter for the type of hunting or fishing that he or she will be doing.
(cr) Authorization. 1. A person holding a current resident or nonresident deer hunting license and a Class A or Class C permit may hunt deer of either sex with a firearm during any season open to hunting of deer with firearms that is established by the department.
2.A Class A permit authorizes the holder to shoot or hunt from a stationary vehicle, to fish or troll as authorized under sub.(8m)(b) [sub. (1)(b)] and to hunt certain game with a crossbow as authorized under ss. 29.103(2)(ar), 29.104(2) and 29.117(2).
[ss. 29.164 (2)(b) , 29.171(2) and 29.216(2)]
3.A Class B permit authorizes the holder to use any of the hunting or fishing methods authorized in this chapter for a holder of a Class A permit that are specifically approved by the department for that Class B permit holder upon issuance or subsequent modification of the Class B permit.
(d)Assistance. 1. A holder of a Class A or Class B permit may be accompanied by a person who is not eligible to apply for a Class A or Class B permit. The accompanying person may not hunt or carry a firearm, bow or crossbow unless that person has been issued the appropriate approval to do so. The assistance rendered by an accompanying person who has not been issued the appropriate approval is limited to field dressing, tagging and retrieving game for the permit holder.
2. A holder of a Class C permit shall be accompanied by a person who is not eligible to apply for a permit under this section. The accompanying person may not hunt or carry a firearm, bow or crossbow unless the person has been issued the appropriate approval to do so. The assistance rendered by an accompanying person may include sighting the firearm, bow or crossbow, identifying the game and field dressing, tagging and retrieving game for the permit holder.
(e)Review of decisions. An applicant denied a permit under this subsection, except a permit under par. (c) 3., may obtain a review of that decision by a licensed physician or a licensed chiropractor designated by the department and with an office located in the department district in which the applicant resides. The department shall pay for the cost of a review under this paragraph unless the denied application on its face fails to meet the standards set forth in par. (c) 1. or 2. A review under this paragraph is the only method of review of a decision to deny a permit under this subsection and is not subject to further review under ch. 227.