Schedule 
       H                                          CERTIFICATION FOR 
     Form IT-140            PERMANENT AND TOTAL DISABILITY                                                                      2022
A person is permanently and totally disabled when he or she is unable to engage in any substantial gainful activity because of a mental or physical condition 
and that disability has lasted or can be expected to last continuously for at least a year or can be expected to lead to death. 
TAXPAYER
If you or another individual were certified by a physician as being permanently and totally disabled during the taxable year 2022 OR were the surviving 
spouse of an individual who had been certified disabled and DIED DURING 2022, a reducing modification to income may be allowed.  
To take the modification, enter the name of the disabled taxpayer and social security number on the certificate below.  Second, have the physician 
complete the remainder of the certificate and return to disabled taxpayer.  Third, complete Schedule M to determine the modification. Last, enclose the 
completed certification with the West Virginia personal income tax return. 
A copy of the federal Schedule R (Part II) may be substituted for the West Virginia Schedule H. 
Note: If an approved Schedule H was provided in a prior year and the disability status did not change for 2022, do not submit this certification with the 
return; however, a copy of the original Schedule H or Schedule R (Part II) must be kept should the Tax Division request verification at a later date. 
PHYSICIAN
If, in your opinion, the individual named on this certification is permanently and totally disabled during 2022, please certify by entering your name, address 
and FEIN number.  Sign and date the certification.
Note: By signing the certification, you agree that the person is permanently and totally disabled when he or she is unable to engage in any substantial 
gainful activity because of a mental or physical condition and that disability has lasted or can be expected to last continuously for at least a year or can be 
expected to lead to death.  

           TAXPAYERS WHO ARE DISABLED DURING 2022 REGARDLESS OF AGE
     I Certify under penalties of perjury that the taxpayer named below was permanently and totally disabled on or before December 31, 2022.

                            Name of Disabled Taxpayer                                                             Social Security Number

                            Physician’s Name                                                     Physician's FEIN Number

                            Physician’s Street Address

                            City                                                           State                       Zip Code

Physicians                                                                    Date
Signature                                                                                  MM    DD                             YYYY

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