Form AR1000DC Disabled Individual Certificate

1 The individual with disabilities is a natural or adopted child or a dependent of the taxpayer 2 The taxpayer maintained supported and cared for the individual with total and permanent disabilities in the taxpayer s home 3 An individual with total and permanent disabilities includes any person who 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 4 A physical or mental impairment is an impairment which results in anatomical physiological or psychological abnormalities which are demonstrable by medically acceptable clinical or laboratory diagnostic techniques 5 The above individual has been diagnosed by a physician as having total and permanent disabilities as outlined in conditions 3 and 4 listed above AR1000DC AR1000DC (R 8/16/2011) ARKANSAS INDIVIDUAL INCOME TAX CERTIFICATE FOR INDIVIDUALS WITH DISABILITIES Name of Individual with Disabilities (cannot be taxpayer or spouse) Spouse s Name Spouse s Social Security Number SSN of Individual with Disabilities Taxpayer s Name Taxpayer s Signature Taxpayer s Social Security Number This certificate must be completed in its entirety to receive the $500 deduction for individuals with disabilities Enter $500 on Line 13 of AR1000ADJ This certificate is good for one year and must be attached to your Individual Income Tax Return To take advantage of this deduction the taxpayer and/or individual must meet the following conditions and standards: Under penalties of perjury I certify that is an individual with total and permanent disabilities based upon the above criteria