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Hawaii Free Printable Form N-172, Rev. 2020, Claim For Tax Exemption by Person with Impaired Sight or Hearing or by Totally Disabled Person and Physician's Certification for 2024 Hawaii Claim for Tax Exemption by Person with Impaired Sight or Hearing

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Claim for Tax Exemption by Person with Impaired Sight or Hearing
Form N-172, Rev. 2020, Claim For Tax Exemption by Person with Impaired Sight or Hearing or by Totally Disabled Person and Physician's Certification

Clear Form FORM N-172 (REV. 2020) STATE OF HAWAII — DEPARTMENT OF TAXATION Claim for Tax Exemption by Person with Impaired Sight or Hearing or by Totally Disabled Person and Physician’s Certification (NOTE: References to “married” and “spouse” are also references to “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. 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,  Persons totally disabled as defined in sec. 235-1, HRS, hereby claims 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. GE ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___ - ___ ___ (b) Doing Business As (DBA) (c) Business Address (d) Type of Business Activity (e) Individual’s Percentage of Ownership: ; Spouse’s percentage: 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 N172_I 2020A 01 VID01 ID NO 01 FORM N-172 (REV. 2020) PAGE 2 Applicant’s Name  ____________________________________ Part II Social Security Number   __________________________ 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?______________________ (Must be done by a qualified otolaryngologist; i.e., Board-certified ear, SECTION B — HEARING EXAMINATION 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?______________________ (Must be done by physicians as described in the definition for “person SECTION C — REPORT ON DISABILITY 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 Address of Blind Applicant Signature of Blind Applicant or witnessed X. If signed X used, two witnesses must sign Social Security Number of Blind Applicant Witness #1 - Signature, If X used. Witness #2 - Signature, If X used.
Extracted from PDF file 2023-hawaii-form-n-172.pdf, last modified September 2003

More about the Hawaii Form N-172 Individual Income Tax TY 2023

We last updated the Claim for Tax Exemption by Person with Impaired Sight or Hearing in February 2024, so this is the latest version of Form N-172, fully updated for tax year 2023. You can download or print current or past-year PDFs of Form N-172 directly from TaxFormFinder. You can print other Hawaii tax forms here.


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Other Hawaii Individual Income Tax Forms:

TaxFormFinder has an additional 164 Hawaii income tax forms that you may need, plus all federal income tax forms.

Form Code Form Name
Form N-11 Individual Income Tax Return (Resident Form)
Form N-200V Individual Income Tax Payment Voucher
Form N-15 Individual Income Tax Return (Nonresidents and Part Year Residents)
Income Tax Instructions Hawaii Income Tax Instruction Booklet
Form N-13 Individual Income Tax Return (Resident Short Form) OBSOLETE

Download all HI tax forms View all 165 Hawaii Income Tax Forms


Form Sources:

Hawaii usually releases forms for the current tax year between January and April. We last updated Hawaii Form N-172 from the Department of Taxation in February 2024.

Show Sources >

About the Individual Income Tax

The IRS and most states collect a personal income tax, which is paid throughout the year via tax withholding or estimated income tax payments.

Most taxpayers are required to file a yearly income tax return in April to both the Internal Revenue Service and their state's revenue department, which will result in either a tax refund of excess withheld income or a tax payment if the withholding does not cover the taxpayer's entire liability. Every taxpayer's situation is different - please consult a CPA or licensed tax preparer to ensure that you are filing the correct tax forms!

Historical Past-Year Versions of Hawaii Form N-172

We have a total of eleven past-year versions of Form N-172 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2023 Form N-172

Form N-172, Rev. 2020, Claim For Tax Exemption by Person with Impaired Sight or Hearing or by Totally Disabled Person and Physician's Certification

2022 Form N-172

Form N-172, Rev. 2020, Claim For Tax Exemption by Person with Impaired Sight or Hearing or by Totally Disabled Person and Physician's Certification

2021 Form N-172

Form N-172, Rev. 2020, Claim For Tax Exemption by Person with Impaired Sight or Hearing or by Totally Disabled Person and Physician's Certification

2020 Form N-172

Form N-172, Rev. 2020, Claim For Tax Exemption by Person with Impaired Sight or Hearing or by Totally Disabled Person and Physician's Certification

2018 Form N-172

Form N-172, Rev. 2018, Claim For Tax Exemption by Person with Impaired Sight or Hearing or by Totally Disabled Person and Physician's Certification

2017 Form N-172

Form N-172, Rev. 2012, Claim For Tax Exemption by Person with Impaired Sight or Hearing or by Totally Disabled Person and Physician's Certification

2016 Form N-172

Form N-172, Rev. 2012, Claim For Tax Exemption by Person with Impaired Sight or Hearing or by Totally Disabled Person and Physician's Certification

Forms 2012 2015 Form N-172

Form N-172, Rev. 2012, Claim For Tax Exemption by Person with Impaired Sight or Hearing or by Totally Disabled Person and Physician's Certification

Forms 2012 2014 Form N-172

Form N-172, Rev. 2012, Claim For Tax Exemption by Person with Impaired Sight or Hearing or by Totally Disabled Person and Physician's Certification

Forms 2012 2012 Form N-172

Form N-172, Rev. 2012, Claim For Tax Exemption by Person with Impaired Sight or Hearing or by Totally Disabled Person and Physician's Certification

Forms 2007 2011 Form N-172

Form N-172, Rev. 2007, Claim For Tax Exemption by Person with Impaired Sight or Hearing or by Totally Disabled Person and Physician's Certification


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