Form Ar1000rc5 - Certificate For Retarded Child
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1STATE OF ARKANSAS
AR1000RC5
Certificate for Retarded Child
INDIVIDUAL INCOME TAX RETURN
Name:
Social Security Number:
This certificate must be completed in its entirety to receive the $500.00 retarded child care credit. The $500.00 tax credit is in addition to your reg-
ular dependent tax credit. It must be attached to your Individual Income Tax Return the first time this credit is taken. It is good for five years from
the date the original tax credit is filed. At the end of five years you must have a new certificate completed and attached to your Individual Income
Tax Return.
To take advantage of this tax credit the taxpayer and/or child must meet all of the following conditions:
1.
The “Child” shall include a person of the taxpayer’s blood or an adopted child without regard to chronological age.
2.
The child must have more than six months Arkansas residency during the tax year and must be dependent on the tax-
payer for more than fifty percent (50%) of his/her maintenance, support and care in the taxpayer’s home.
3.
The taxpayer must have resided in Arkansas for more than six (6) months prior to the end of the year.
4.
The child must be mentally deficient to the extent that he/she is incapable of managing himself/herself or his/her affairs and must be eligi-
ble for admission to the Arkansas Human Development Center.
5.
The child has not resided in the Arkansas Human Development Center more than six (6) months of the tax year. (The tax credit is compen-
sation for your care of the child in the home.)
6.
The child's mental deficiency has been determined by a Medical Doctor, Licensed Psychologist, or a Licensed Psychological Examiner in
good standing with the Arkansas Board of Examiners in Psychology whose diagnosis indicates retardation within the meaning of Act 6 of
1955.
7.
This $500.00 tax credit is not being claimed by any other taxpayer.
_____________________________________________________
_____________________________________________
Child’s Full Name
Relationship to Taxpayer
_____________________________________________________
_____________________________________________
I.Q or Retardation Rating
Child's Physical Age
Does the child reside in your home more than six (6) months of every year?
Yes
No
The above child has been diagnosed as mentally retarded by a Medical Doctor, Licensed Psychological Examiner (functioning under the supervi-
sion of a Licensed Psychologist) whose license is in good standing with the Arkansas Board of Examiners in Psychology.
I certify that the information listed above is true and correct.
____________________________________________________________________
_____________________________
Doctor or Examiner's Signature
Date
____________________________________________________________________
_____________________________
Doctor’s or Examiner’s Name
Office Phone
Street Address
City
State
Zip
____________________________________________________________________
_____________________________
Taxpayer’s Signature
Date
AR1000RC5 (R 9/98)
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