a substantial impairment to the individual s ability to function without appropriate support services
Cerebral Palsy Epilepsy Autism Down Syndrome Spina Bifida
Doctor or Examiner s Name Telephone Number
Doctor or Examiner s Signature Date
including but not limited to planned recreational activities medical services such as physical
Intellectual Disability
Qualifying Individual s Name Social Security Number Relationship to Taxpayer
regard to chronological age or a dependent within the meaning of ACA 26 51 501(a)(3)(B)? Yes No
Street Address City State Zip
Taxpayer s Signature Date
therapy and speech therapy and possibilities for sheltered employment or job training? Yes No
1 Was the individual a person of the taxpayer s blood or an adopted child without
2 Did the individual reside in your home more than one half of the tax year? Yes No
3 Was the individual dependent on the taxpayer for over one half of his/her support during the tax year? Yes No
4 Did the developmental disability originate before the individual attained the age of 22? Yes No
5 Will the developmental disability continue or can be expected to continue indefinitely and constitute
AR1000RC5
AR1000RC5 (R 8/19/15)
ARKANSAS INDIVIDUAL INCOME TAX
CERTIFICATE FOR INDIVIDUALS WITH
Check the box for the diagnosis:
DEVELOPMENTAL DISABILITIES
DO NOT ADD ADDITIONAL BOXES
I certify that the information listed above is true and correct
Initial Diagnosis Date
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
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 licensed physician 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
This certificate must be completed in its entirety to receive the $500 credit for individuals with developmental disabilities
To take advantage of this credit the individual with a developmental disability must meet all of the following conditions:
to your individual income tax return The credit is in addition to your regular dependent tax credit
