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a = Gt CANIFO@MOS © ACALTM AWD WELFARE ac \ of ‘ . » — Se neste OF SOWIIT Pavecnrs ' ° cou . \ 2 UNTY USE ONLY . Hit 20 OAYS T APPLICANT masa . . . —_—— o. VERIFICATION OF PHYSICAL OR MENTAL INCAPACITY OUSTRICT mumaca La 4 eccorcenca with Calilornia Foug Stamo Manual Saetion 63—222 iaaaging in gaintul amploymont may Be exempted from the food Slamp work registration requirement. Any such exemption “wet by clearly documonted by other obvious physical evidence of disability, reecipe of OASO!, or by specitice documentary ‘vidunes of ineapacity. Whon properly complatod, this lorm may furnish the requisite documentary avidenco, “ART I. “ourw STATEMENT Pe CRF fs TAS M galnful omploymeant for the following feason(s): (List and describe lve «3, persons who arg physically or mentally incapaoie of » Cartify that | am Incapable of engaging. the nature of ynur Gisabitity) J. . ~ further authorize the release of al! Informat! On regarding my disability to the . EAL rounty Welfare Cepartment, ‘ . PPLICANT sicnaTuRE > ART It. sthreuenn OF PHYSICIAN | OR OTHER MEDICAL AUTHORITY AWE: x * ~° ». \<i \\ SEW aN Tee: VAY oan | LEP 4) WA ertity that sically Naha of enga ure of tha disability) * Is, Ia my professional opinion, mentally and/or sing In gaintul employment as a result of the following Sengition(s}: (List and daserive ‘(tne ae 3 lnadtlty td engage in gainful employment wilt continue: : M™Snontly OQ Up to 3 months 3 to 6 months aher (explain) jature oF PHYSIC M, MS BICAL AUTHORITY [ASE MAIL THIS STATEMENT 70; © 6 months to 1 year