Form Ar1113 - Phenylketonuria Disorder And Other Metabolic Disorders Credit - 2012
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1AR1113
2012
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 2012 for medically necessary foods and
low protein modified food products: .........................................................................................................1
00
2. Unused credit from 2010 and 2011: .........................................................................................................2
00
3. Total credit available for 2012: (Add Lines 1 and 2) .................................................................................3
00
$2,400
4. Maximum allowable credit: .......................................................................................................................4
00
5. Your total allowable credit: (Enter the smaller of Line 3 or 4) ...................................................................5
00
6. Enter net tax due (Line 36, Form AR1000F/AR1000NR) after
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
00
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
AR1113 (R 6/13/12)
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