Form N 172 – Fill Out and Use This PDF

Form N 172 is a mandatory document issued by the US Citizenship and Immigration Services (USCIS). It is filled out by applicants seeking either diverse or fewer immigration benefits. Whether someone seeks permanent residence within the US or a business entreating employment petitions, Form N-172 typically presents itself as an essential part of the paperwork required for each respective scenario. Obtaining all the supplementary documentation necessary for such applications can be tedious, however completing this form continues to remain a vital factor in solidifying an application.

Form N 172 PDF Details

When you're starting a business, there are many important documents you need to file with the state. One of these is Form N 172, which is the Massachusetts Business Certificate of Formation. This document proves that your business exists and is registered with the state. Filing this form is the first step in starting your business in Massachusetts. Learn more about what's required to file Form N 172 and how to get started today.

Question	Answer
Form Name	Form N 172
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	ASA, 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
	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)
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,		 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

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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:

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!

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.

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.

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.

Form N 172 – Fill Out and Use This PDF

Form N 172 PDF Details

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