Form Ar1000dc - Disabled Child Certificate Individual Income Tax Return
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1STATE OF ARKANSAS
AR1000DC
Disabled Child Certificate
INDIVIDUAL INCOME TAX RETURN
Name:
Social Security Number:
Child’s Name:
This certificate must be completed in its entirety to receive the $500.00 disabled child 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 child must meet the following conditions and standards:
1.
The child is the natural or adopted child of the taxpayer.
2.
The taxpayer is maintaining, supporting and caring for a totally and permanently disabled child in his/her home.
3.
Totally and permanently disabled means and includes any child 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 abnormalities which are
demonstrable by medically acceptable clinical or laboratory diagnostic techniques.
5.
The above child has been diagnosed by a physician as totally and permanently disabled as outlined in conditions 3 and 4 listed above.
I certify that ________________________________________________________________________is a totally and permanently
disabled child based upon the above criteria.
____________________________________________________________________
______________________________
Doctor Signature
Date
____________________________________________________________________
______________________________
Doctor’s Name (print or type)
Office Phone
Street Address
City
State
Zip
AR1000DC (R9/98)
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