AR1000DC
2014
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ARKANSAS INDIVIDUAL INCOME TAX
CERTIFICATE FOR INDIVIDUALS WITH DISABILITIES
Taxpayer’s Name
Taxpayer’s Social Security Number
Spouse’s Name
Spouse’s Social Security Number
Name of Individual with Disabilities
SSN of Individual with Disabilities
(cannot be taxpayer or spouse)
This certificate must be completed in its entirety to receive the $500 adjustment for individuals with disabilities. Enter
$500 on Line 13 of AR1000ADJ. This certificate is good for one year, and must be attached to your Individual
Income Tax Return.
To take advantage of this adjustment, the taxpayer and/or individual must meet the following conditions and
standards:
1. The individual with disabilities is a natural or adopted child, or a dependent of the taxpayer.
2. The taxpayer maintained, supported, and cared for the individual with total and permanent disabilities in the
taxpayer’s home.
3. An individual with total and permanent disabilities 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 having total and permanent disabilities as outlined
in conditions 3 and 4 listed above.
Under penalties of perjury, I certify that _____________________________________________________is an individual
with total and permanent disabilities based upon the above criteria.
__________________________________________________________________________
_______________
Taxpayer’s Signature
Date
AR1000DC (R 2/3/14)
1
