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

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