Form AR1000RC5 Individuals With Developmental Disabilities Certificate

(ii) Is attributable to any other condition found to be closely related to intellectual disability because it results in an impairment of general intellectual functioning or adaptive behavior similar to that of persons with intellectual dis abilities or requires treatment and services similar to those required for such persons; or (iii) Is attributable to dyslexia resulting from a disability described in (A)(i) of this section; and A) Self Care: Ability to care for one s own toileting grooming dressing and eating needs B) Understanding and Use of Language: Ability to communicate needs and responses to others using a formal speech system C) Learning: Ability to process information retain it and apply it to different situations as appropriate to the individual s age level Cerebral Palsy Epilepsy Autism Down Syndrome Spina Bifida D) Mobility: Ability to move self from place to place either by walking or propelling adaptive equipment Doctor or Examiner s Name Telephone Number Doctor or Examiner s Signature Date E) Self Direction: Ability to make appropriate decisions regarding time travel finances and health F) Capacity for Independent Living: Ability to cook shop clean and otherwise maintain self in an independent living situation Intellectual Disability Enter IQ score or check the appropriate box: Mild Moderate Severe NOTE: The individual must have been eligible for admission into an intermediate care facility for individuals with developmental disabilities (ICF/MR) To meet ICF/MR level of care an individual must have had substantial func tional limitation in three or more of the following areas of major life activity: Qualifying Individual s Name Social Security Number Relationship to Taxpayer Street Address City State Zip Taxpayer s Signature Date (A) (i) Is attributable to intellectual disability cerebral palsy epilepsy autism Down syndrome or spina bifida; or (B) Originates before the person attains the age of twenty two (22) years; and (C) Has continued or can be expected to continue indefinitely; and (D) Constitutes a substantial impairment to the person s ability to function without appropriate support services including but not limited to planned recreational activities medical services such as physical therapy and speech therapy and possibilities for sheltered employment or job training 1 Intellectual disability: Individuals are eligible for services if their I Q scores fall two or more standard deviations below the mean of a standardized test or their condition is closely related to intellectual disability by virtue of their adaptive behavior function and the nature of the treatment and services they require You must enter the I Q score or check the intellectual disability level in the space provided on the front of the form 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 Cerebral palsy: As established by the results of a medical examination by a licensed physician 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 Epilepsy: As established by the results of a neurological examination by a licensed neurologist and/or licensed physician 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 4 Autism: As established by the results of a team evaluation by a licensed physician and a licensed psychologist or psychological examiner 4 This $500 tax credit is not being claimed by any other taxpayer 5 Down Syndrome: As established by the results of a medical examination by a licensed physician 6 Spina Bifida: As established by the results of a medical examination by a licensed physician A developmental disability is a disability which: AR1000RC5 AR1000RC5 (R 8/16/2011) AR1000RC5 Instr (R 8/16/2011) ARKANSAS INDIVIDUAL INCOME TAX CERTIFICATE FOR INDIVIDUALS WITH Check the appropriate box of the developmental disability and list the I Q score (if required) in the space provided on the AR1000RC5 Check the box for the diagnosis: DEVELOPMENTAL DISABILITIES DIAGNOSED DISABILITY: Did the individual reside in your home more than six (6) months of the year? Yes No DO NOT ADD ADDITIONAL BOXES I certify that the information listed above is true and correct INSTRUCTIONS FOR AR1000RC5 NOTE: Each of these six conditions independent of each other is sufficient for determination of eligibility This means a person who has been diagnosed with an intellectual disability does not have to have autism epilepsy cerebral palsy Down syndrome or spina bifida Conversely a person who has autism cerebral palsy Down syndrome spina bifida or epilepsy does not have to have intellectual disabilities to be eligible Spouse s Name Spouse s Social Security Number Taxpayer s Name Taxpayer s Social Security Number The above individual has been diagnosed with a developmental disability by a medical doctor a licensed psychologist or a licensed psychological examiner 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 and/or individual must meet all of the following conditions: