AR1113
2015
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ARKANSAS INDIVIDUAL INCOME TAX
PHENYLKETONURIA DISORDER AND OTHER
METABOLIC DISORDERS CREDIT
Taxpayer’s Name:
Taxpayer’s Social Security Number:
Dependent’s Name:
Dependent’s Social Security Number:
A credit of up to $2,400.00, per year, per child, is allowed to individuals or to families with a dependent child or children
with Phenylketonuria (PKU), Galactosemia, Organic Acidemias, and Disorders of Amino Acid Metabolism for expenses
incurred for the purchase of medically necessary foods and low protein modified food products. Any unused credit amount
may be carried forward for an additional two (2) years. This form must be completed in its entirety to receive the credit.
Complete one form for each child with an allowable disorder.
1. Enter the total cost paid in 2015 for medically necessary foods and
00
low protein modified food products: .........................................................................................................1
00
2. Unused credit from 2013 and 2014: .........................................................................................................2
00
3. Total credit available for 2015: (Add Lines 1 and 2) .................................................................................3
$2,400
00
4. Maximum allowable credit: .......................................................................................................................4
00
5. Your total allowable credit: (Enter the smaller of Line 3 or 4) ...................................................................5
6. Enter net tax due (Line 36, Form AR1000F/AR1000NR) after
00
deducting all credits except business incentive credits and this credit: .................................................6
00
7. Credit allowed: (Enter the smaller of Line 5 or 6 here and on Line 4, AR1000TC) ..................................7
PLEASE SIGN HERE:
Under penalties of perjury, I declare that the above individual has been diagnosed with phenylketonuria
disorder and the information entered is true and correct.
Taxpayer
Date
Spouse (if applicable)
Date
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AR1113 (R 5/27/15)