Fillable Form Ar1000dc - Disabled Individual Certificate

Form Ar1000dc - Disabled Individual Certificate - 2005

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DCN - FOR ELECTRONIC FILING USE ONLY

AR1000DC

2005

STATE OF ARKANSAS

Disabled Individual Certificate

INDIVIDUAL INCOME TAX RETURN

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Taxpayer’s Name (as shown on return)

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. This deduction is taken in the

adjustment section of your Arkansas Individual Income Tax Return. 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 his/her home.

3. Totally and permanently disabled means and includes any individual who is 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 the anatomical, physiological or psychological abnor-

malities 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 11/05)

Form Ar1000dc - Disabled Individual Certificate - 2005

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