Form AR1000RC5 Fillable Individuals With Developmental Disabilities Certificate
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

(: 1) Unchecked (: 2) Unchecked (: 3) Unchecked (: On) Unchecked (: On) Unchecked (50%) (A)(i) (B) Originates before the person attains the age of twenty two (22) years; (Cerebral Palsy) Unchecked (City) (Clear Form of all entries) CLICK HERE TO CLEAR FORM (D) Constitutes a substantial impairment to the person s ability to function without appropriate support services including (Date) (Date) (Doctor or Examiner s Name) (Epilepsy) Unchecked (iii) (Intellectual Disability Enter IQ score) Unchecked (or check the appropriate box: Mild) (Qualifying Individual s Name) (Relationship to Taxpayer) (Social Security Number) (Social Security Number) (Spouse s Name) (State) (Street Address) (Taxpayer s Name) (Telephone Number) (Zip) A developmental disability is a disability which: A) Self Care: Ability to care for one s own toileting grooming dressing and eating needs Ability abnormalities which are demonstrable by medically acceptable clinical or laboratory diagnostic techniques adaptive behavior function and the nature of the treatment and services they require You must enter the I Q affairs and was eligible for admission to one of the Arkansas Human Development Centers (See ACA 20 48 206 ) age level appropriate AR1000RC5 AR1000RC5 (R 2/3/14) AR1000RC5 Instr (R 10/4/12) ARKANSAS INDIVIDUAL INCOME TAX attributable autism Autism Autism: As established by the results of a team evaluation by a licensed physician and a licensed psychologist or B) Understanding and Use of Language: Ability to communicate needs and responses to others using a formal below the mean of a standardized test or their condition is closely related to intellectual disability by virtue of their bifida Bifida bifida; but not limited to planned recreational activities medical services such as physical therapy and speech therapy and C) Learning: Ability to process information retain it and apply it to different situations as appropriate to the individual s cerebral cerebral Cerebral Palsy: As established by the results of a medical examination by a licensed physician CERTIFICATE FOR INDIVIDUALS WITH Check the appropriate box of the developmental disability and list the I Q score (if required) in the space Check the box for the diagnosis: continue continued Conversely D) Mobility: Ability to move self from place to place either by walking or propelling adaptive equipment decisions dependent described DEVELOPMENTAL DISABILITIES developmental disabilities (ICF/MR) To meet ICF/MR level of care an individual must have had substantial functional DIAGNOSED DISABILITY: Did the individual reside in your home more than six (6) months of the year? disabilities disability DO NOT ADD ADDITIONAL BOXES Doctor or Examiner s Name Doctor or Examiner s Signature Date Down Syndrome: As established by the results of a medical examination by a licensed physician dyslexia E) Self Direction: eligibility This means a person who has been diagnosed with an intellectual disability does not have to have autism eligible epilepsy epilepsy Epilepsy: As established by the results of a neurological examination by a licensed neurologist and/or licensed expected F) Capacity for Independent Living: Ability to cook shop clean and otherwise maintain self in an independent fifty finances health his/her home The individual had mental or physical disabilities to the extent that he/she was incapable of managing himself/herself or his/her I certify that the information listed above is true and correct impairment of general intellectual functioning or adaptive behavior similar to that of persons with intellectual disabilities 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 indefinitely; individual Initial Diagnosis Date INSTRUCTIONS FOR AR1000RC5 intellectual Intellectual Disability Enter IQ score or check the appropriate box: Mild Intellectual disability: Individuals are eligible for services if their I Q scores fall two or more standard deviations Is attributable to any other condition found to be closely related to intellectual disability because it results in an 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 limitation in three or more of the following areas of major life activity: living situation maintenance meaning of 26 51 501(a)(3)(b) Moderate NOTE: Any of these six conditions independent of each other is sufficient for determination of NOTE: The individual must have been eligible for admission into an intermediate care facility for individuals with of the following conditions: palsy palsy percent person persons; physician possibilities for sheltered employment or job training provided on the AR1000RC5 psychological examiner Qualifying Individual s Name regarding required requires resulting score or check the intellectual disability level in the space provided on the front of the form section; services Severe similar Social Security Number Relationship to Taxpayer speech system spina spina Spina Bifida: As established by the results of a medical examination by a licensed physician Spouse s Name Spouse s Social Security Number State Street Address support syndrome syndrome taxpayer taxpayer s Taxpayer s Name Taxpayer s Signature Date Taxpayer s Social Security Number Telephone Number The above individual has been diagnosed with a developmental disability by a medical doctor a licensed psychologist or a licensed psychological examiner the date the original tax credit is filed At the end of five (5) years you must have a new certificate completed and attached The individual was a person of the taxpayer s blood or an adopted child without regard to chronological age or a dependent within the The individual was unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental This $500 tax credit is not being claimed by any other taxpayer This certificate must be completed in its entirety to receive the $500 credit for individuals with developmental disabilities those To take advantage of this credit the taxpayer must live in Arkansas and the individual must live in the taxpayer s home The individual must meet all to your individual income tax return The credit is in addition to your regular dependent tax credit travel treatment twelve (12) months A physical or mental impairment is an impairment that results from anatomical physiological or psychological