The Disability Affidavit for Tax Relief is a form from the Loudoun County Commissioner of the Revenue that a medical provider completes to verify an applicant's permanent and total disability. It is submitted with an application for Real Estate and/or Vehicle Tax Relief, so it is one of the forms used with Loudoun County property tax relief. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the official PDF is published by the county at the address linked here.
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What is TED24-1225?
The Disability Affidavit for Tax Relief is the Loudoun County Commissioner of the Revenue form used for disability verification by a medical provider when someone applies for Real Estate and/or Vehicle Tax Relief.
The form has two parts. In the first, the applicant signs an Authorization to Disclose Health Information, naming the licensed medical provider who may release identifiable health information to the Commissioner of the Revenue's Office. In the second, the provider signs an affidavit before a notary public. The provider swears or affirms to be a medical doctor licensed in Virginia, or an active duty military officer practicing medicine, and states that the applicant's condition is totally disabling and permanent in nature.
The affidavit quotes Code of Virginia 58.1-3217: "permanently and totally disabled" means unable to engage in any substantial gainful activity because of a medically determinable physical or mental impairment or deformity that can be expected to result in death or to last for the person's lifetime.
This form is one of four ways to show permanent and total disability. The others are disability certification from the Social Security Administration, the Department of Veterans Affairs or the Railroad Retirement Board, which do not use this form. The footer prints the code TED24-1225.
Who needs to file TED24-1225?
Applicants for Loudoun County Real Estate and/or Vehicle Tax Relief who choose to prove permanent and total disability with sworn medical affidavits use this form. The applicant completes the authorization section; the provider completes the affidavit.
- Applicant: signs the authorization naming the licensed medical provider.
- Provider: a medical doctor licensed to practice in Virginia, or an active duty military officer who practices medicine with the U.S. Armed Forces. Each practitioner uses a separate copy of the form.
- Two practitioners: the county asks for sworn affidavits from two medical doctors licensed in Virginia or two military officers who practice medicine. At least one must have examined the applicant; the other may have reviewed the applicant's medical records.
You do not need this form if you verify disability with certification from the Social Security Administration, the Department of Veterans Affairs or the Railroad Retirement Board. Staff can answer questions at [email protected] or 703-737-8557.
When to file TED24-1225
Submit this form when you apply for Real Estate and/or Vehicle Tax Relief, if you are verifying disability through a medical provider. The form prints no separate due date, so it travels with the tax relief application. The county's pages at loudoun.gov/TaxRelief-Older-Disabled and loudoun.gov/COR-Forms carry the tax relief information and forms; check them or call 703-737-8557 for application dates. Have each provider examine the patient or review the medical file and sign before a notary before you submit, because the affidavit records the date of the examination or file review.
Documents you need
- A second Disability Affidavit for Tax Relief, completed by a second practitioner, when you verify disability with sworn affidavits: the county asks for two medical doctors licensed in Virginia or two military officers who practice medicine.
- Your signed Authorization to Disclose Health Information, part of this form, naming the licensed medical provider.
- Disability certification from the Social Security Administration, the Department of Veterans Affairs or the Railroad Retirement Board, only if you verify disability that way instead of using affidavits.
How to fill out TED24-1225
Confirm you need this form
Use it if you verify permanent and total disability through medical providers when applying for Real Estate and/or Vehicle Tax Relief. Use a separate copy for each practitioner.
Enter applicant name and address
In the Authorization to Disclose Health Information, print your full legal name and your street address in Loudoun County, Virginia.
Name the licensed medical provider
Enter the name of the licensed medical provider you authorize to disclose your health information to the Commissioner of the Revenue's Office.
Sign and date the authorization
The applicant signs at Applicant Signature and enters the Date Signed.
Enter provider name and credentials
The provider prints their full legal name and credentials, and confirms they are a medical doctor licensed in Virginia or an active duty military officer practicing medicine.
Record the examination or review
Enter the date, check whether the provider thoroughly examined the patient or completed a review of the medical file, and enter the patient's name.
Enter the date disability began
The provider fills in the date the disability began, which the affidavit states prevents substantial gainful activity and is expected to result in death or last for life.
Provider signs and gives address
The provider signs and dates the affidavit and enters their street address, city and ZIP.
Complete the notary block
The provider signs before a notary public. The notary enters the city/county, day, month and year, signature, registration number, commission expiration and seal.
Repeat for the second practitioner
If you verify through affidavits, have a second practitioner complete another copy; at least one of the two must have examined you.
Review and download the PDF
Check every field and signature, then download or print the completed PDF from FillingPDF and submit it as described under How to submit.
How to submit TED24-1225
You can submit the form in person or by mail.
- In person: at the Leesburg office, 1 Harrison Street SE, 1st Floor, or the Sterling office, 46000 Center Oak Plaza. Both are open 8:30 AM to 5:00 PM, Monday through Friday during County business hours; the county encourages scheduling an appointment to reduce your wait.
- By mail: Loudoun County Commissioner of the Revenue, Attn: Tax Exemptions & Deferrals, PO Box 8000, Leesburg, VA 20177-9804.
The county's forms page says completed forms that contain sensitive personal identifying information should be submitted through its secure Document Upload Portal; ask staff whether that applies to your package. For help with a specific topic, Tax Relief, Exemptions & Deferrals is [email protected] or 703-737-8557. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Submitting a single affidavit when you verify through medical providers; the county asks for sworn affidavits from two practitioners, using this form for each.
- Having both practitioners only review records; at least one must have examined the applicant.
- Provider signing the affidavit without a notary; the affidavit must be signed before a notary public, who completes the notary block.
- Using a provider who is not a medical doctor licensed in Virginia or an active duty military officer practicing medicine.
- Leaving unchecked the box showing whether the provider examined the patient or reviewed the medical file.
- Omitting the date the disability began or the date of the examination or file review.
- Skipping the applicant's Authorization to Disclose Health Information signature and date.
- Mailing the form to a street address instead of PO Box 8000, Leesburg, VA 20177-9804, Attn: Tax Exemptions & Deferrals.
Frequently asked questions
What is the Disability Affidavit for Tax Relief?
It is a Loudoun County Commissioner of the Revenue form on which a licensed medical provider swears, before a notary, that an applicant is permanently and totally disabled under Virginia law. It is used with applications for Real Estate and/or Vehicle Tax Relief.
Do I need two affidavits for Loudoun County tax relief?
If you verify disability with sworn affidavits, yes: the county asks for two, from medical doctors licensed in Virginia or military officers who practice medicine. Use this form for each. At least one practitioner must have examined you; the other may have reviewed your records.
Who can sign the provider section?
A medical doctor licensed to practice in Virginia, or an active duty military officer practicing medicine with the U.S. Armed Forces. The provider signs before a notary public, who completes the notary block.
Is there another way to prove disability without this form?
Yes. You may provide disability certification from the Social Security Administration, the Department of Veterans Affairs or the Railroad Retirement Board instead of medical affidavits. This form is needed only for the affidavit route.
Where do I send the Disability Affidavit for Tax Relief?
Submit it in person at 1 Harrison Street SE, 1st Floor, Leesburg, or 46000 Center Oak Plaza, Sterling, or mail it to Loudoun County Commissioner of the Revenue, Attn: Tax Exemptions & Deferrals, PO Box 8000, Leesburg, VA 20177-9804.
What does the applicant have to complete?
Only the Authorization to Disclose Health Information: your full legal name, street address, the licensed medical provider's name, your signature and the date signed. The provider completes the affidavit section.
Can I fill out this affidavit online on FillingPDF?
You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is independent of Loudoun County and does not submit the form; you deliver it to the Commissioner of the Revenue yourself, and the provider still signs before a notary.
Who can I contact with questions about the form?
For Tax Relief, Exemptions & Deferrals, email [email protected] or call 703-737-8557. To request language assistance or an accommodation for accessing the form, contact [email protected] or 703-737-8557/TTY-711, with advance notice.
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