Form Ar1000rc5 - Arkansas Certificate For Individuals With Developmental Disabilities - 2014

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AR1000RC5
2014
CLICK HERE TO CLEAR FORM
ARKANSAS INDIVIDUAL INCOME TAX
CERTIFICATE FOR INDIVIDUALS WITH
DEVELOPMENTAL DISABILITIES
Taxpayer’s Name
Taxpayer’s Social Security Number
Spouse’s Name
Spouse’s Social Security Number
This certificate must be completed in its entirety to receive the $500 credit for individuals with developmental disabilities.
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 must live in Arkansas and the individual must live in the taxpayer’s home. The individual must meet all
of the following conditions:
1.
The individual was 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 was dependent on the taxpayer for more than fifty percent (50%) of his/her maintenance, support, and care in the taxpayer’s
home. The individual had mental or physical disabilities to the extent that he/she was incapable of managing himself/herself or his/her
affairs and was eligible for admission to one of the Arkansas Human Development Centers. (See ACA 20-48-206.)
3.
The individual was 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. 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 tax credit is not being claimed by any other taxpayer.
4.
Qualifying Individual’s Name
Social Security Number
Relationship to Taxpayer
Did the individual reside in your home more than six (6) months of the year?
Yes
No
Check the box for the diagnosis:
Cerebral Palsy Epilepsy Autism Down Syndrome Spina Bifida
Intellectual Disability - Enter IQ score ________or check the appropriate box: Mild
Moderate
Severe
DO NOT ADD ADDITIONAL BOXES
The above individual has been diagnosed with a developmental disability by a medical doctor, a licensed psychologist, or a licensed psychological examiner.
I certify that the information listed above is true and correct.
Initial Diagnosis Date
Doctor or Examiner’s Signature
Date
Doctor or Examiner’s Name
Telephone Number
Street Address
City
State
Zip
Taxpayer’s Signature
Date
AR1000RC5 (R 2/3/14)

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