SAMPLE STATEMENT to receive exemption on Federal Income Tax. This or a similar statement must be signed by a licensed Ophthalmologist and submitted with the filed income tax form each year for which exemption is claimed.

 

 

Dear Sir or Madam:

This is to certify that _________________________________________ is legally blind. This definition of legal blindness corresponds with Chapter 413.021(1) of the Florida Statues and is as follows:

The person's central visual acuity does not exceed 20/200 in the better eye with correcting lenses, or a disqualfying field defect in with the peripheral field has contracted to such an extent that the widest diameter or visual field subtends an angular distance no great than 20 degrees.

If you need more information, please contact us at the telephone number of address listed below:

Signed: ______________________________________

Date: ________________________

Address:
_____________________________________
_____________________________________
_____________________________________

 Telephone #: __________________

 

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