Form AR1000DC Fillable Disabled Individual Certificate
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

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 3 An individual with total and permanent disabilities includes any person who was unable to engage in any 4 A physical or mental impairment is an impairment which results in anatomical physiological or psychological 5 The above individual has been diagnosed by a physician as having total and permanent disabilities as outlined $500 on Line 13 of AR1000ADJ This certificate is good for one year and must be attached to your Individual abnormalities which are demonstrable by medically acceptable clinical or laboratory diagnostic techniques AR1000DC AR1000DC (R 4/23/15) 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 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