The First Responder’s Employer Certification of Injury is the form, issued under Section 196.102, Florida Statutes, on which an employer or a volunteer’s supervisor certifies that a first responder’s injury was caused by service in the line of duty. It is one of the Alachua County property tax forms published by the Alachua County Property Appraiser, and the form says to file it with the county property appraiser. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the original PDF is published by the Alachua County Property Appraiser.
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What is First Responder’s Employer Certification of Injury – Alachua County, FL?
The First Responder’s Employer Certification of Injury is the form, cited to Section 196.102, Florida Statutes, in which an employer or a volunteer’s supervisor describes an incident and certifies that a first responder’s injury was caused by service in the line of duty and left the first responder totally and permanently disabled.
The form is completed by the employer, not by the first responder. It records the employee’s name and job title, the supervisor’s name, the employing entity’s name and address, the location and date of the incident, and the incident details. The employer certifies three things: the injury or injuries were directly and proximately caused by service in the line of duty, there was no willful negligence on the part of the first responder, and the injury or injuries are the sole cause of the first responder’s total and permanent disability. The statement is made as true and correct to the best of the signer’s knowledge.
The certificate must be supplemented with existing documentation of the incident or event that caused the injury, such as an accident or incident report. The form also carries a note on cardiac events: a total and permanent disability resulting from a cardiac event does not qualify for the exemption unless the conditions printed on the form are met.
The form is filed with the county property appraiser. It is a certification that accompanies a claim for the exemption; it is not the exemption application itself.
Who needs to file First Responder’s Employer Certification of Injury – Alachua County, FL?
The employer of a first responder, or the supervisor of a volunteer first responder, completes this form. The form is headed "To be completed by employer or volunteer’s supervisor," and the signature block is for the employer or its designee, with a title and date.
Use it when a first responder has a total and permanent disability that the employer can certify resulted from an injury caused by service in the line of duty, without willful negligence on the first responder’s part, and as the sole cause of the disability.
Special rule for cardiac events: a total and permanent disability that results from a cardiac event does not qualify for the exemption unless the cardiac event occurs no later than 24 hours after the first responder performed nonroutine stressful or strenuous physical activity in the line of duty. The first responder must also give the employer a certificate from the treating cardiologist, with any pertinent supporting documentation, stating within a reasonable degree of medical certainty that the activity directly and proximately caused the cardiac event and that a preexisting vascular disease did not cause it.
The form does not describe any other person who may sign for the employer beyond the employer’s designee.
When to file First Responder’s Employer Certification of Injury – Alachua County, FL
The form is completed after the incident that injured the first responder, once the employer has the incident documentation to attach, such as an accident or incident report. The form prints no separate due date and does not state a filing window.
For a disability resulting from a cardiac event, the employer needs the treating cardiologist’s certificate from the first responder before certifying, because the form conditions qualification on it. The 24-hour limit printed on the form concerns when the cardiac event occurred after the strenuous activity; it is not a filing deadline. For any deadline tied to the exemption itself, check with the Alachua County Property Appraiser.
Documents you need
- Existing documentation of the incident or event that caused the injury, such as an accident or incident report; the employer certificate must be supplemented with it.
- For a total and permanent disability resulting from a cardiac event: a certificate from the first responder’s treating cardiologist, given to the employer, stating within a reasonable degree of medical certainty that the nonroutine stressful or strenuous activity directly and proximately caused the cardiac event.
- For a cardiac event: the same cardiologist certificate must state that the cardiac event was not caused by a preexisting vascular disease, and it comes with any pertinent supporting documentation.
How to fill out First Responder’s Employer Certification of Injury – Alachua County, FL
Enter the employee and job title
In the section to be completed by the employer or volunteer’s supervisor, write the first responder’s name in Employee Name and the position in Job Title.
Enter the supervisor’s name
In Supervisor Name, write the name of the supervisor, or the volunteer’s supervisor, completing the form.
Identify the employing entity
Write the entity’s name in Employing Entity Name and its full address in Employing Entity Address.
Give the incident location and date
Under Description of Incident, enter the place in Location of Incident and the date in Date of Incident.
Describe the incident details
In Incident Details, describe the incident or event that caused the injury. Keep the description consistent with the accident or incident report you will attach.
Review the cardiac event note
If the disability resulted from a cardiac event, confirm that the conditions in the printed note are met, including the 24-hour limit and the treating cardiologist’s certificate, before you certify.
Gather supporting documentation
Collect the existing documentation of the incident, such as an accident or incident report, to supplement the certificate. Add the cardiologist’s certificate and supporting documents for a cardiac event.
Sign, title and date the certification
Read the certification, then have the employer or its designee sign it and enter the Title and Date. The signer attests the statement is true and correct to the best of their knowledge.
Review and download the completed PDF
Check that every field is complete and matches the incident documentation. Download or print the completed PDF from FillingPDF and file it with the county property appraiser as described under How to submit.
How to submit First Responder’s Employer Certification of Injury – Alachua County, FL
The form states one channel: file it with the county property appraiser. It prints no mailing address, portal or appointment rule.
- County property appraiser: this version is published by the Alachua County Property Appraiser at the URL on this page. Contact that office for its current address and accepted ways of delivering the form.
- What to include: the signed certification together with the existing documentation of the incident, such as an accident or incident report. For a cardiac event, include the treating cardiologist’s certificate and supporting documentation that the first responder gave the employer.
FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Filing the certification without existing documentation of the incident, such as an accident or incident report; the form says the certificate must be supplemented with it.
- Having the first responder complete the form; it is to be completed by the employer or the volunteer’s supervisor.
- Signing the certification when the injury was not the sole cause of the total and permanent disability, or when willful negligence by the first responder was involved.
- Submitting a cardiac-event disability without the treating cardiologist’s certificate and supporting documentation.
- Certifying a cardiac event that occurred more than 24 hours after the first responder’s nonroutine stressful or strenuous activity in the line of duty.
- Leaving the incident location, date or details blank, or leaving the title and date next to the signature empty.
- Filing the form with an office other than the county property appraiser.
Frequently asked questions
What is the First Responder’s Employer Certification of Injury?
It is the form, cited to Section 196.102, Florida Statutes, in which an employer or volunteer’s supervisor certifies that a first responder’s injury was caused by service in the line of duty and is the sole cause of the first responder’s total and permanent disability.
Who fills out the employer certification of injury?
The employer or the volunteer’s supervisor. The form is headed "To be completed by employer or volunteer’s supervisor," and the signature block is for the employer or its designee, with title and date.
Where do I file the First Responder’s Employer Certification of Injury?
With the county property appraiser, as the form states. It prints no address or portal, so contact the Alachua County Property Appraiser, which publishes this version, for its current address and accepted ways to deliver the form.
What do I attach to the employer certification of injury?
Existing documentation of the incident that caused the injury, such as an accident or incident report. For a disability from a cardiac event, also include the treating cardiologist’s certificate and supporting documentation the first responder gave the employer.
Does a cardiac event qualify for the exemption?
Only if it meets the form’s conditions: the cardiac event occurs no later than 24 hours after nonroutine stressful or strenuous physical activity in the line of duty, and a treating cardiologist’s certificate gives the causation statements printed on the form.
Can I fill out this form online?
You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not file the form; you file it with the county property appraiser yourself.
Does the form have a deadline?
No due date is printed on the form. For any deadline connected to the exemption under Section 196.102, check with the Alachua County Property Appraiser.
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