Washington REV 64 0095: Proof of Disability Statement

Washington's property tax exemption and deferral programs for seniors and people with disabilities need proof of disability when the applicant has no written Social Security or Veterans Administration determination, or when the county assessor asks. This one-page statement records the date the person became disabled and whether they can engage in substantial gainful activity. The assessor needs it before approving the exemption or deferral.

Who completes it

The applicant's name, account or parcel number and date go at the top. A licensed physician or certified physician assistant (medical or osteopathic), a licensed psychologist for mental impairments, or a licensed podiatrist for foot impairments checks one certification, signs under penalty of perjury, and prints name and address.

Submitting and payment

How to submit it
Return it to the applicant, who files it with the county assessor's office along with REV 64 0002 (exemption) or REV 64 0011 (deferral).
Who pays
The statement lists no fee or billing code for the certification.

Good to know

  • Disability follows 42 U.S.C. 423(d)(1)(A): inability to engage in substantial gainful activity due to an impairment expected to result in death or last at least 12 continuous months.
  • The four options are: disabled since a date and expected to continue until a stated date, disabled and permanent, disabled but able to work, or not disabled.
  • The Department of Revenue publishes the statement only as a Word document (REV 64 0095, 6/26/19); alternate formats are available on request.
  • A written SSA or VA decision of permanent disability is an alternative, but the county assessor can still ask for this statement.

Get the official form

Download the current version from the source each time; forms change without notice.

Proof of Disability Statement

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Frequently asked questions

Who can sign Washington's Proof of Disability Statement?

A licensed physician or certified physician assistant (medical or osteopathic), a licensed or certified psychologist for disabling mental impairments, or a licensed podiatrist for impairments of the foot. The signer declares under penalty of perjury under Washington law that the statements are true and correct.

Is REV 64 0095 needed if the applicant gets Social Security disability?

Usually not. The statement is required when there is no written acknowledgment or decision of permanent disability from the Social Security Administration or Veterans Administration. The county assessor can still request it, so applicants should follow the assessor's instructions.

Does the doctor give an end date on REV 64 0095?

Only if the disability is expected to be temporary. The first option records the onset date and the date the disability is expected to continue until; the second records the onset date and states it is expected to be permanent. Two other options certify ability to work despite a disability, or no disability.