Legal Blindness Form PDF Details

When you are considering a legal case, it is important to have all of the relevant information in order to make an informed decision. The Legal Blindness Form can help you do just that. This form is designed to provide you with a clear overview of your case, and allow you to make an educated decision about whether or not to pursue legal action. With the help of this form, you can be sure that you are making the best possible decision for yourself and your loved ones.

You may find information about the type of form you intend to complete in the table. It can show you the time you will need to complete legal blindness form, what fields you will have to fill in and some other specific facts.

Form NameLegal Blindness Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesconfirmation of legal blindness form, sample letter for irs of legal blindness, irs legally blind form, confirmation legal blindness

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Confirmation of legal blindness is required for special consideration or disability services from the IRS, Social Security, and other federal, state, and private organizations. The federal government defines blindness as follows:

[T]he term "blindness" means central visual acuity of 20/200 or less in the better eye with the use of a correcting lens. An eye which is accompanied by a limitation in the fields of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees shall be considered for purposes in this paragraph as having a central visual acuity of 20/200 or less.

Social Security Act: 42 U.S.C. § 416(i)(1)(B) (Supp. IV 1986).[1]

Translation: A person is considered legally blind if the vision in the right eye and the left eye (both eyes) is 20/200 or less when wearing glasses or contacts or both, or if the field of vision for both eyes together is 20 degrees or less.


Name: _________________________________________ Date of Birth: ____________


Best corrected vision: OD (Right Eye): ____________. OS (Left Eye): ____________.

OU (Both Eyes): _____________________.

Visual field (in degrees): _____________________.

Specific eye condition(s):

Certifying Authority:

I certify that ____________________________ is legally blind in both eyes as specified

in the federal definition quoted above.

(Signed) __________________________________________ (Date) ___________


Please attach your business card OR print/type your name, profession, and address here:

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