Form N 172 PDF Details

In the state of Hawaii, the Form N-172 serves as a crucial document for individuals with impaired sight or hearing or those who are totally disabled, providing a pathway to claim tax exemptions under the General Excise Tax and/or Income Tax Laws. Issued by the Department of Taxation and last revised in 2012, this form requires comprehensive details from the applicant, including personal identification, type of disability, and a section dedicated to physician’s certification. The references within the form to marital status are inclusive, acknowledging civil unions alongside traditional marriages, which indicates the state's broader understanding of modern relationships. Part I of the form allows individuals—or in certain cases, corporations, partnerships, or LLCs where all members meet the disability criteria—to specify the nature of their exemption claim, whether for general excise tax or income tax, reflecting the form’s adaptability to different taxpayer needs. Meanwhile, Part II necessitates a detailed certification from qualified professionals like ophthalmologists, otolaryngologists, or licensed physicians and includes provisions for the authorization of information release to facilitate further services for the applicant. This form not only underscores the importance of accommodating individuals with disabilities within the tax system but also highlights the procedural and verification steps necessary to ensure these exemptions are granted appropriately.

QuestionAnswer
Form NameForm N 172
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesASA, LLC, ANSI, hawaii form n 172

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FORM

 

N-172

STATE OF HAWAII — DEPARTMENT OF TAXATION

(REV. 2012)

Claim for Tax Exemption by Person with Impaired Sight

 

or Hearing or by Totally Disabled Person and Physician’s Certification

(NOTE: References to “married”, “unmarried”, and “spouse” also means “in a civil union”, “not 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

who is (check applicable category)

 

 

 

(check all applicable categories)

 

 

 

 

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,

 

 

Person totally disabled as defined in sec. 235-1, HRS,

 

 

 

 

 

 

hereby claim 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. W ___ ___ ___ ___ ___ ___ ___ ___ - ___ ___

(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 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

FORM N-172

 

(REV. 2012)

PAGE 2

Applicant’s Name ___________________________________

Social Security Number _________________________

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? ____________________

 

 

 

SECTION B — HEARING EXAMINATION

(Must be done by a qualified otolaryngologist; i.e., Board-certified ear,

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? ____________________

 

 

 

SECTION C — REPORT ON DISABILITY

(Must be done by physicians as described in the definition for “person

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

Signature of Blind Applicant or witnessed X. If signed X used, two witnesses must sign

Witness #1 - Signature, If X used.

Address of Blind Applicant

Social Security Number of Blind Applicant

Witness #2 - Signature, If X used.

FORM N-172

How to Edit Form N 172 Online for Free

By using the online PDF editor by FormsPal, it is easy to complete or edit state right here. FormsPal development team is ceaselessly working to expand the editor and make it much easier for users with its extensive functions. Enjoy an ever-improving experience now! Getting underway is simple! All that you should do is adhere to these easy steps directly below:

Step 1: First, access the pdf tool by pressing the "Get Form Button" above on this webpage.

Step 2: As you access the PDF editor, there'll be the form made ready to be completed. Apart from filling out different blanks, you can also perform many other things with the file, that is adding any textual content, changing the initial text, inserting graphics, placing your signature to the form, and a lot more.

This document requires particular info to be typed in, therefore be sure you take whatever time to type in exactly what is asked:

1. It is very important complete the state properly, so take care when filling out the sections that contain all of these blank fields:

Simple tips to complete ANSI stage 1

2. Once your current task is complete, take the next step – fill out all of these fields - A person totally disabled as, Person totally disabled as defined, hereby claim the benefits provided, requested See separate, General Excise Tax sections and, a General Excise Hawaii Tax ID No, b Doing Business As DBA, c Business Address, d Type of Business Activity, Individuals Percentage of Ownership, Spouses percentage, Income Tax section HRS for, a Name on tax return if joint show, and I declare under the penalties set with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Part no. 2 for filling in ANSI

3. Within this step, examine I declare under the penalties set, Taxpayer Signature individual, Date, Title, NOTE DISABILITY OR IMPAIRMENT MUST, OPTOMETRISTS ETC ON THE BACK OF, and FORM N. Each one of these need to be filled out with highest accuracy.

The way to fill in ANSI portion 3

4. Filling in FORM N REV, PAGE, Applicants Name Social Security, Part II, Physicians or optometrists, SECTION A EYE EXAMINATION, Must be done by a qualified, Diagnosis Vision without, Is this applicants visual acuity, Yes, Yes, OD OS, Yes, If Yes when, and SECTION B HEARING EXAMINATION is key in the next step - you should definitely don't rush and be attentive with each and every field!

Yes, Yes, and Diagnosis Vision without in ANSI

5. As you come near to the completion of this document, there are just a few more points to do. Notably, Revised Statutes and to apprise me, Print Full Name of Blind Applicant, Date, Address of Blind Applicant, Signature of Blind Applicant or, Social Security Number of Blind, Witness Signature If X used, Witness Signature If X used, and FORM N should be done.

Step number 5 in filling out ANSI

A lot of people generally make mistakes while filling out Print Full Name of Blind Applicant in this section. Remember to revise everything you type in here.

Step 3: Before obtaining the next step, ensure that all blank fields were filled out as intended. Once you are satisfied with it, click on “Done." Sign up with FormsPal today and immediately gain access to state, available for downloading. Every single edit you make is conveniently kept , making it possible to edit the pdf later if required. We don't share any information that you enter when completing forms at our website.

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