Form Ar1000rc5 - Certificate For Developmentally Disabled Individual
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1STATE OF ARKANSAS
AR1000RC5
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 the 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 tax credit the taxpayer and/or child must meet all of the following conditions:
1.
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).
2.
The individual must be dependent on the taxpayer for more than fifty percent (50%) of his/her maintenance, support, and care in the taxpay-
er’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.
3.
The individual has NOT resided in any of the Arkansas Human Development Centers more than six (6) months of the tax year.
4.
The individual must be unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impair-
ment 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. 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.
5.
This $500.00 is not being claimed by any other taxpayer.
______________________________________________________
_____________________
_____________________
Individual’s Name
Social Security Number
Relationship to Taxpayer
_________________________ __________________________
Does the individual reside in your home
Diagnosed Disability
I.Q. Score (if required)
more than six (6) months of every year?
Yes
No
The above child has been diagnosed as developmentally disabled by a medical doctor, 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
Office Phone
Street Address
City
State
Zip
____________________________________________________________________
_______________________________
Taxpayer’s Signature
Date
AR1000RC5 (R 11/99)
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