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, “agte Gt CAN iP Q@med © MCAL TM AND WELFARE AC \ of ° 2 Wy SEPAPTASUP OF SOIT DavenTs ' ° “ue . \ LUNTY USE OMLy . . 4 . . . AS SURED, 0 TS APPLICANT wane ‘ . {- = * VE AATAS (We { CALL NUMER OATC OF APPLICATION t t s VERIFICATION OF PHYSICAL OR MENTAL INCAPACITY OUSTRMICT mumsca 7 accorcence with California Food Stame Manual Saetion 62~22563, persons who ara physically or mentally incapaaie of | asging ia gaintul employmont may beg exempted trom ine flaod Stamp work registration requirement. Any such exemption ssl by clesrly documonted by otthar obvious physical evidence of Cisability, reccipt of OASOI, or by specific documentary “vidunce of incapacity, Whon properly complated, this form may furnish the requisite cocumentary evidence. “ART 1. APPLICANT STATEMENT . —.. : ay ° LE Ver * LWT A: n galntut ompleyment for the following reason(s): (List and oe | kre » Cartify that | am Incapable of engaging Scribe the nature of your disability) ‘ further authorize the release of all Information regarding my disability to the : ER Zz ounty Welfare Department, ' : g , q . . . . PPLICANT SIGNATURE D C . Ori : s Sm £80") 7e-3 DATE Ava . lg ? 2 , a Ue WG _ PPLICANT ADDRESS (number, street, eity, zip) 7 5 7. \AT Ih, sthreuent OF PHYSICIAN OR OTHER MEDICAL AUTHORITY Le) > aoe WE: MS ~“t », \<r i\ IEW ee ree: ne can itty that sically Ineababie of enga we of tha disability) ° eh Cl . e Is, la my professional Opinion, mentally and/or cing In gainful employment as a resuit of the following condition(s): (List and coscribe ‘tna ‘4 ‘ - Inadlitty td engage In cainfut employmont wil! centiaue: , - M™Iaently © Up to 3 months 3 to 6 months i ASE MAIL THIS STATEMENT cher (explain) . ‘SDICAL AUTHORITY? G & months to 1 year