The First Responder’s Employer Certificate is the form, printed under the title "First Responder’s Employer Certification of Injury" and citing Section 196.102, Florida Statutes, on which an employer or a volunteer’s supervisor describes and certifies a first responder’s injury. The Pinellas County Property Appraiser publishes it, so it belongs among the Pinellas County property tax forms that the office makes available. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the original is published by the Pinellas County Property Appraiser at pcpao.gov.
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What is First Responder’s Employer Certificate – Pinellas County, FL?
The First Responder’s Employer Certificate is a one-page form, titled "First Responder’s Employer Certification of Injury" on its face, that an employer or a volunteer’s supervisor completes to certify that a first responder’s injury was caused by service in the line of duty. It cites Section 196.102, Florida Statutes, and is published by the Pinellas County Property Appraiser.
The form is completed by the employer or supervisor, not by the first responder. It records the employee’s name and job title, the supervisor’s name and job title, and the name and address of the employing entity. A Description of Incident block then asks for the location of the incident, the date of the incident and the incident details.
The form states that the employer certificate must be supplemented with existing documentation of the incident or event that caused the injury, such as an accident or incident report.
It also carries a note on 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, and the first responder gives the employer a certificate from the treating cardiologist, with any pertinent supporting documentation.
The form ends with the employer’s certification and a signature block. It does not itself grant anything: it is the employer’s statement about the injury.
Who needs to file First Responder’s Employer Certificate – Pinellas County, FL?
The employer of a first responder, or the supervisor of a volunteer first responder, completes this certificate. The form is headed "To be completed by employer or volunteer’s supervisor," so the person certifying the injury is the one who signs, and prints their name and job title beside the signature.
The first responder is the person the certificate is about. The form says the injury or injuries must have been directly and proximately caused by service in the line of duty, without willful negligence on the part of the first responder, and must be the sole cause of the first responder’s total and permanent disability.
Cardiac cases have an extra condition. A total and permanent disability that results from a cardiac event does not qualify for the exemption unless the event occurs no later than 24 hours after nonroutine stressful or strenuous physical activity in the line of duty. In that case the first responder must provide the employer with a certificate from the treating cardiologist 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.
When to file First Responder’s Employer Certificate – Pinellas County, FL
The form prints no due date of its own; the triggering event is a first responder’s line-of-duty injury that the employer or volunteer’s supervisor is asked to certify. The employer completes the certificate together with existing documentation of the incident, such as an accident or incident report, because the form says the certificate must be supplemented with it.
For a total and permanent disability that results from a cardiac event, timing matters at the incident itself: the cardiac event must occur 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 the treating cardiologist’s certificate, so the employer should have it in hand before certifying.
Date the certificate on the line next to the signature when you sign it.
Documents you need
- An accident report, incident report or other existing documentation of the incident or event that caused the injury; the form says 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, with any pertinent supporting documentation.
- The cardiologist’s certificate must state, within a reasonable degree of medical certainty, that nonroutine stressful or strenuous activity directly and proximately caused the cardiac event and that a preexisting vascular disease did not.
How to fill out First Responder’s Employer Certificate – Pinellas County, FL
Enter employee name and job title
In the top block, type the first responder’s name in Employee Name and their position in Job Title.
Enter the supervisor’s details
In Supervisor Name/Job Title, enter the name and job title of the supervisor, including a volunteer’s supervisor where the first responder is a volunteer.
Identify the employing entity
Enter the Employing Entity Name and the Employing Entity Address.
Give the incident location and date
Under Description of Incident, complete Location of Incident and Date of Incident.
Describe the incident
In Incident Details, describe the incident or event that caused the injury. Keep the description consistent with the accident or incident report that must supplement the form.
Check the cardiac event note
If the disability resulted from a cardiac event, confirm the event occurred no later than 24 hours after nonroutine stressful or strenuous activity in the line of duty and that you hold the treating cardiologist’s certificate.
Read the certification statement
Read the sentence beginning "I certify that the first responder’s injury or injuries were directly and proximately caused by service in the line of duty." Sign only if it is true and correct to the best of your knowledge.
Sign, print name and date
Sign on the Signature line, then enter your Name/Job Title and the Date.
Review and download the completed PDF
Check every field, then download or print the completed PDF from FillingPDF. Assemble it with the incident documentation described under How to submit.
How to submit First Responder’s Employer Certificate – Pinellas County, FL
The form names no mailing address, portal or office hours of its own. It is published by the Pinellas County Property Appraiser at https://www.pcpao.gov/sites/default/files/FirstResponder_EmployerCertificate.pdf.
- Complete and sign: the employer or volunteer’s supervisor fills in the form and signs it, with name, job title and date.
- Attach incident documentation: the form says the certificate must be supplemented with existing documentation of the incident, such as an accident or incident report.
- Cardiac cases: the first responder gives the employer the treating cardiologist’s certificate and any pertinent supporting documentation.
Contact the Pinellas County Property Appraiser through its website, pcpao.gov, to confirm where the completed certificate goes. FillingPDF lets you fill out and download the PDF; submission follows the agency’s channels.
Common mistakes to avoid
- Sending the certificate without an accident or incident report or other existing documentation of the incident, which the form says must supplement it.
- Having the first responder complete the form; it is headed "To be completed by employer or volunteer’s supervisor."
- Certifying a cardiac-event disability without the treating cardiologist’s certificate and supporting documentation.
- Describing a cardiac event that occurred more than 24 hours after the nonroutine stressful or strenuous activity; the note says such a disability does not qualify.
- Leaving the Location of Incident, Date of Incident or Incident Details blank.
- Signing without printing the name and job title and the date beside the signature.
- Certifying an injury that was not the sole cause of the first responder’s total and permanent disability, contrary to the certification statement.
Frequently asked questions
What is the First Responder’s Employer Certificate?
It is a one-page form, titled First Responder’s Employer Certification of Injury and citing Section 196.102, Florida Statutes, on which an employer or volunteer’s supervisor certifies that a first responder’s injury was caused by service in the line of duty.
Who completes the First Responder’s Employer Certificate?
The employer, or the supervisor when the first responder is a volunteer. The form is headed "To be completed by employer or volunteer’s supervisor," and that person signs the certification and prints their name, job title and the date.
Is this a Pinellas County property tax form?
It is published by the Pinellas County Property Appraiser and cites Section 196.102, Florida Statutes. The form itself is the employer’s certification of the injury, not an application, and it refers to qualifying for "the exemption."
What do I need to attach to the employer certificate?
Existing documentation of the incident, such as an accident or incident report. The form says the employer certificate must be supplemented with it. For a cardiac event, the first responder’s treating cardiologist’s certificate is also needed.
Does a disability from a cardiac event qualify?
Only if the cardiac event occurs no later than 24 hours after nonroutine stressful or strenuous physical activity in the line of duty, and the treating cardiologist certifies that the activity caused it and a preexisting vascular disease did not.
Can I fill out the First Responder’s Employer Certificate online?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not file or send the certificate; the form is handled through the Pinellas County Property Appraiser’s channels.
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