Form Ar1000dc - Disabled Individual Certificate - 2009
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1AR1000DC
2009
2009A1
ARKANSAS INDIVIDUAL INCOME TAX
DISABLED INDIVIDUAL CERTIFICATE
DCN - FOR ELECTRONIC FILING USE ONLY
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Taxpayer’s Name
Taxpayer’s Social Security Number
Disabled Individual’s Name
Disabled Individual’s Social Security Number
This certificate must be completed in its entirety to receive the $500 Disabled Individual Deduction. Enter $500 on Line 11
of AR1000ADJ. This certificate is good for one year, and must be attached to your Individual Income Tax Return.
To take advantage of this deduction, the taxpayer and/or individual must meet the following conditions and
standards:
1. The disabled individual is a natural or adopted child, or a dependent of the taxpayer.
2. The taxpayer maintained, supported, and cared for the totally and permanently disabled individual in the
taxpayer’s home.
3. A totally and permanently disabled individual includes any person who was unable to engage in any substantial
gainful activity by reason of any medically determinable physical or mental impairment which can be expected
to result in death or has lasted or can be expected to last for a continuous period of not less than twelve (12)
months.
4. A physical or mental impairment is an impairment which results in anatomical, physiological, or psychological
abnormalities which are demonstrable by medically acceptable clinical or laboratory diagnostic techniques.
5. The above individual has been diagnosed by a physician as totally and permanently disabled as outlined in
conditions 3 and 4 listed above.
Under penalties of perjury, I certify that _____________________________________________________is a totally and
permanently disabled individual based upon the above criteria.
__________________________________________________________________________
_______________
Taxpayer’s Signature
Date
AR1000DC (R 10/5/09)
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