$500 on Line 13 of AR1000ADJ This certificate is good for one year and must be attached to your Individual
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(Date)
(DC 2)
(DC 4)
(Disabled Individual s Name (cannot be taxpayer or spouse))
(Disabled Individual s Social Security Number)
(permanently disabled individual based upon the above criteria)
(Spouse s Name)
(Taxpayer s Name)
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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
An individual with total and permanent disabilities includes any person who was unable to engage in any
AR1000DC
AR1000DC (R 2/3/14)
ARKANSAS INDIVIDUAL INCOME TAX
be expected to result in death or has lasted or can be expected to last for a continuous period of not less than
CERTIFICATE FOR INDIVIDUALS WITH DISABILITIES
in conditions 3 and 4 listed above
Income Tax Return
Name of Individual with Disabilities (cannot be taxpayer or spouse)
Spouse s Name
Spouse s Social Security Number
SSN of Individual with Disabilities
standards:
substantial gainful activity by reason of any medically determinable physical or mental impairment which can
taxpayer s home
Taxpayer s Name
Taxpayer s Signature
Taxpayer s Social Security Number
The above individual has been diagnosed by a physician as having total and permanent disabilities as outlined
The individual with disabilities is a natural or adopted child or a dependent of the taxpayer
The taxpayer maintained supported and cared for the individual with total and permanent disabilities in the
This certificate must be completed in its entirety to receive the $500 adjustment for individuals with disabilities Enter
To take advantage of this adjustment the taxpayer and/or individual must meet the following conditions and
twelve (12) months
Under penalties of perjury I certify that is an individual
with total and permanent disabilities based upon the above criteria
