Form Ar1000rc5 - Certificate For Individuals With Developmental Disabilities - 2013

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AR1000RC5

2013

ARKANSAS INDIVIDUAL INCOME TAX

CERTIFICATE FOR INDIVIDUALS WITH

DEVELOPMENTAL DISABILITIES

Taxpayer’s Name

Taxpayer’s Social Security Number

Spouse’s Name

Spouse’s Social Security Number

This certificate must be completed in its entirety to receive the $500 credit for individuals with developmental disabilities.

It must be attached to your individual income tax return the first time this credit is taken. It is good for five (5) years from

the date the original tax credit is filed. At the end of five (5) years you must have a new certificate completed and attached

to your individual income tax return. The credit is in addition to your regular dependent tax credit.

To take advantage of this credit the taxpayer must live in Arkansas and the individual must live in the taxpayer’s home. The individual must meet all

of the following conditions:

The individual was a person of the taxpayer’s blood or an adopted child without regard to chronological age or a dependent within the

meaning of §26-51-501(a)(3)(b).

The individual was dependent on the taxpayer for more than fifty percent (50%) of his/her maintenance, support, and care in the taxpayer’s

home. The individual had mental or physical disabilities to the extent that he/she was incapable of managing himself/herself or his/her

affairs and was eligible for admission to one of the Arkansas Human Development Centers. (See ACA 20-48-206.)

The individual 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. A physical or mental impairment is an impairment that results from anatomical, physiological, or psychological

abnormalities which are demonstrable by medically acceptable clinical or laboratory diagnostic techniques.

This $500 tax credit is not being claimed by any other taxpayer.

Qualifying Individual’s Name

Social Security Number

Relationship to Taxpayer

Did the individual reside in your home more than six (6) months of the year?

Yes

Check the box for the diagnosis:

Cerebral Palsy Epilepsy Autism Down Syndrome Spina Bifida

Intellectual Disability - Enter IQ score ________or check the appropriate box: Mild

Moderate

Severe

DO NOT ADD ADDITIONAL BOXES

The above individual has been diagnosed with a developmental disability by a medical doctor, a licensed psychologist, or a licensed psychological examiner.

I certify that the information listed above is true and correct.

Initial Diagnosis Date

Doctor or Examiner’s Signature

Date

Doctor or Examiner’s Name

Telephone Number

Street Address

City

State

Zip

Taxpayer’s Signature

Date