Form TC-40D Fillable Dependent with a Disability Exemption
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

Is claimed as a dependent on the taxpayer s federal individual income tax return for the taxable year; Is claimed as a dependent on the taxpayer s federal individual income tax return for the taxable year; and Is claimed as a dependent on the taxpayer's federal individual income tax return for the taxable year; Is determined eligible by an IEP team under rules the State Board of Education special education adopts in Is eligible for services under Title 62A Chapter 5 Services for People with Disabilities; and Is enrolled in an education program for students with disabilities that is authorized under Section 53A 15 301 or is a Is identified under guidelines of the Department of Health as qualified for the Baby Watch Early Intervention Program Is not enrolled in an education program for students with disabilities authorized under 53A 15 301 Is not receiving residential services from the Division of Services for People with Disabilities created under Is not the taxpayer or the taxpayer s spouse; (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (Clear form) Clear form (text) (text) (text) (text) 1 800 662 4335 ext 6700 if outside Salt Lake area 1 The dependent is 18 years of age or older for whom an exemption is claimed on the taxpayer s federal 1 The dependent is 2 years of age or younger for whom an exemption is claimed on the taxpayer s federal 1 The dependent is 21 years of age or younger for whom an exemption is claimed on the taxpayer s federal 2 The dependent is eligible for services under Title 62A Chapter 5 Services for People with Disabilities; and 2 The dependent is identified under Utah Department of Health guidelines as qualified for the Baby Watch Early 2 The dependent is not receiving residential services from the Division of Services for People with Disabilities under 3 The dependent is enrolled in a public education program for students with disabilities under Section 53A 15 301 or 3 The dependent is not enrolled in an education program for students with disabilities under Section 53A 15 301 4 The dependent has been determined eligible by an IEP team under State Board of Education special education 801 538 7587 A principal or representative from the school in which the student is enrolled is authorized to certify the A dependent adult with a disability means an individual 18 years age or older who: A dependent child with a disability means an individual 2 years of age or younger who: A eligible student with a disability means an individual 21 years age or younger who: accordance with Title 63G Chapter 3 Utah Administrative Rulemaking Act as having a disability classified as autism are not eligible Authorized certification signature (required) Autism Hearing Impairment Other Health Impairment care physician or a licensed psychologist familiar with the individual certifying the dependent qualifies Date signed Deafness deafness developmental delay dual sensory impairment (deaf/blind) hearing impairment intellectual disability Dependent Adult with a Disability Dependent Child with a Disability Dependent with a Disability Exemption for the tax year ending Dependent with a Disability Exemption Instructions Developmental Delay Do not send this form with your return Keep this form and all related documents with your records DSPD services certification may be by a DSPD support coordinator If not receiving DSPD services certification may be Dual Sensory Impairment (deaf/blind) eligibility of the student for this exemption Eligible Student with a Disability for Infants and Toddlers For more information and certification contact the Utah Department of Health Baby Watch Early Intervention Program for For more information contact the Division of Services for People with Disabilities (DSPD) 195 North 1950 West 3rd Floor For more information contact the special education office of your local school district or charter school your local school for the additional dependent with a disability exemption on the taxpayer s Utah individual income tax return Form TC 40D must be signed by an authorized person certifying the dependent with a disability qualifies to be claimed General Instructions If you checked: If you need an accommodation under the Americans with Disabilities Act contact us at 801 297 3811 individual income tax return and who is not the taxpayer or the taxpayer s spouse; individual income tax return; and Infants and Toddlers P O Box 144720 Salt Lake City UT 84114 4720 telephone 801 584 8226 or 1 800 961 4226 Intellectual Disability Intervention Program for Infants and Toddlers is a recipient of a scholarship awarded under Title 53A Chapter 1a Part 7 Carson Smith Scholarships for Students made by a primary care physician or licensed psychologist Multi disability multi disability orthopedic impairment other health impairment traumatic brain injury or visual impairment Name of person/child with a disability (cannot be the taxpayer or taxpayer's spouse) or the Utah State Office of Education 250 East 500 South P O Box 144200 Salt Lake City UT 84114 4200 telephone Orthopedic Impairment Part 1 Dependent Child with a Disability (2 years of age or younger) Part 1 obtain the signature of a representative of the Utah Department of Health certifying the dependent qualifies Part 2 Eligible Student with a Disability (21 years of age or younger) Part 2 obtain the signature of school district or charter school representative certifying the dependent qualifies Part 3 Dependent Adult with a Disability (18 years of age or older) Part 3 obtain the signature of a Division of Services for People with Disabilities support coordinator the primary Print name recipient of a scholarship awarded under Title 53A Chapter 1a Part 7 Carson Smith Scholarships for Students with REQUIRED Authorized Certification Signature Rev 12/12 rules under Title 63G Chapter 3 Utah Administrative Rulemaking Act as having one of the following disabilities: Salt Lake City Utah 84116 telephone 801 538 4200 or TTY 801 538 4192; dspd utah gov If a person is enrolled in section 62A 5 102 or a school established under Title 53A Chapter 25b Utah Schools for the Deaf and the Blind ; Section 62A 5 102 or a school established under Title 53A Chapter 25b Utah Schools for the Deaf and the Blind; See instructions on reverse side Social security number Special Needs Act; and Students with learning disabilities emotional disturbances and communication speech language disorders only Tax forms may be obtained at tax utah gov/forms or by calling 801 297 6700 or Taxpayers claiming the additional exemption for a dependent with a disability must complete a form TC 40D each year Taxpayer's name TC 40D Telephone number Title/Agency/Degree To qualify as a dependent adult with a disability all of the following conditions must be met: To qualify as a dependent child with a disability all of the following conditions must be met: To qualify as an eligible dependent student with a disability all of the following conditions must be met: Traumatic Brain Injury TTY 801 297 2020 Please allow three working days for a response Utah State Tax Commission Visual Impairment with Special Needs Act; and You must obtain an authorized certification signature below in order to claim the exemption