Form Tc-40d - Dependent With A Disability Exemption

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Utah State Tax Commission
TC-40D
Dependent with a Disability Exemption
for the tax year ending
.
Rev. 12/12
You must obtain an authorized certification signature below in order to claim the exemption.
Do not send this form with
your
return. Keep
this form and all related documents with your records.
See instructions on reverse side.
Taxpayer's name
Social security number
Name of person/child with a disability (cannot be the taxpayer or taxpayer's spouse)
Social security number
Part 1 - Dependent Child with a Disability (2 years of age or younger)
To qualify as a dependent child with a disability, all of the following conditions must be met:
1. The dependent is 2 years of age or younger for whom an exemption is claimed on the taxpayer’s federal
individual income tax return; and
2. The dependent is identified under Utah Department of Health guidelines as qualified for the Baby Watch Early
Intervention Program for Infants and Toddlers.
Part 2 - Eligible Student with a Disability (21 years of age or younger)
To qualify as an eligible dependent student with a disability, all of the following conditions must be met:
1. The dependent is 21 years of age or younger for whom an exemption is claimed on the taxpayer’s federal
individual income tax return, and who is
not
the taxpayer or the taxpayer’s spouse;
2. The dependent is
not
receiving residential services from the Division of Services for People with Disabilities under
section 62A-5-102 or a school established under Title 53A, Chapter 25b, Utah Schools for the Deaf and the Blind
;
3. The dependent is enrolled in a public education program for students with disabilities under Section 53A-15-301, or
is a recipient of a scholarship awarded under Title 53A, Chapter 1a, Part 7, Carson Smith Scholarships for Students
with Special Needs Act; and
4. The dependent has been determined eligible by an IEP team under State Board of Education special education
rules under Title 63G, Chapter 3, Utah Administrative Rulemaking Act, as having one of the following disabilities:
Autism
Hearing Impairment
Other Health Impairment
Deafness
Intellectual Disability
Traumatic Brain Injury
Developmental Delay
Multi-disability
Visual Impairment
Dual Sensory Impairment (deaf/blind)
Orthopedic Impairment
Students with learning disabilities, emotional disturbances and communication speech language disorders only
are
not
eligible.
Part 3 - Dependent Adult with a Disability (18 years of age or older)
To qualify as a dependent adult with a disability, all of the following conditions must be met:
1. The dependent is 18 years of age or older for whom an exemption is claimed on the taxpayer’s federal
individual income tax return, and who is
not
the taxpayer or the taxpayer’s spouse;
2. The dependent is eligible for services under Title 62A, Chapter 5, Services for People with Disabilities; and
3. The dependent is
not
enrolled in an education program for students with disabilities under Section 53A-15-301.
REQUIRED - Authorized Certification Signature
If you checked:
Part 1
, obtain the signature of a representative of the Utah Department of Health certifying the dependent qualifies.
Part 2
, obtain the signature of school district or charter school representative certifying the dependent qualifies.
Part 3
, obtain the signature of a Division of Services for People with Disabilities support coordinator, the primary
care physician, or a licensed psychologist familiar with the individual, certifying the dependent qualifies.
Authorized certification signature (required)
Date signed
X
Print name
Title/Agency/Degree
Telephone number

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