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AR1000RC5

STATE OF ARKANSAS

Certificate for Developmentally Disabled Individual

INDIVIDUAL INCOME TAX RETURN

Taxpayer’s Name (as shown on return)

Social Security Number

This certificate must be completed in its entirety to receive the $500.00 developmentally disabled individual credit. 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 and/or individual must meet all of the following conditions:

The Individual shall include 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 must be dependent on the taxpayer for more than fifty percent (50%) of his/her maintenance, support, and care in the taxpayer’s home. He/

she must be mentally or physically deficient to the extent that he/she is incapable of managing himself/herself or his/her affairs and must be eligible for

admission to one of the Arkansas Human Development Centers.

The individual has NOT resided in any of the Arkansas Human Development Centers more than six(6) months of the tax year.

The individual must be unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can

be excepted 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 $500.00 tax credit is not being claimed by any other taxpayer.

Qualifying Individual’s Name

Social Security Number

Relationship to Taxpayer

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

Yes

Please check the box for the diagnosis:

Cerebral Palsy

Epilepsy

Autism

Down’s Syndrom

Mental Retardation - IQ or Retardation Rating _______________

The above individual has been diagnosed as developmentally disabled by a medical doctor, a licensed psychologist, or a licensed psychological examiner.

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

Doctor or Examiner’s Signature

Date

Doctor or Examiner’s Name

Telephone Number

Street Address

City

State

Zip

Taxpayer’s Signature

Date

AR1000RC5 (R 09/00)