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Get AR AR1000RC5 2019-2022

PRINT FORM AR1000RC5 CLEAR FORM ITDD181 ARKANSAS INDIVIDUAL INCOME TAX CERTIFICATE FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES Primary s Legal Name Primary s Social Security Number Spouse s Legal Name Spouse s Social Security Number 7KLV FHUWL FDWH PXVW EH FRPSOHWHG LQ LWV HQWLUHW WR UHFHLYH WKH FUHGLW IRU LQGLYLGXDOV ZLWK GHYHORSPHQWDO GLVDELOLWLHV W PXVW EH DWWDFKHG WR RXU LQGLYLGXDO LQFRPH WD UHWXUQ WKH UVW WLPH WKLV FUHGLW LV WDNHQ W LV JRRG IRU YH HDUV IURP WKH GDWH WKH RULJLQDO WD FUHGLW LV OHG W WKH HQG RI YH HDUV RX PXVW KDYH D QHZ FHUWL FDWH FRPSOHWHG DQG DWWDFKHG WR RXU LQGLYLGXDO LQFRPH WD UHWXUQ 7KH FUHGLW LV LQ DGGLWLRQ WR RXU UHJXODU GHSHQGHQW WD FUHGLW To take advantage of this credit the individual with a developmental disability PXVW PHHW DOO RI WKH IROORZLQJ FRQGLWLRQV Was the individual a person of the taxpayer s blood or an adopted child without regard to chronological age or a dependent within the meaning of ACA 26-51-501 a 3 B Yes No Did the individual reside in your home more than one-half of the tax year Did the developmental disability originate before the individual attained the age of 22 LOO WKH GHYHORSPHQWDO GLVDELOLW FRQWLQXH RU FDQ EH H SHFWHG WR FRQWLQXH LQGH QLWHO DQG FRQVWLWXWH a substantial impairment to the individual s ability to function without appropriate support services including but not limited to planned recreational activities medical services such as physical therapy and speech therapy and possibilities for sheltered employment or job training Qualifying Individual s Name Social Security Number Relationship to Taxpayer KHFN WKH ER IRU WKH GLDJQRVLV DO NOT ADD ADDITIONAL BOXES HUHEUDO 3DOV SLOHSV XWLVP RZQ 6 QGURPH 6SLQD L GD Intellectual Disability The above individual has been diagnosed with a developmental disability by a licensed physician a licensed psychologist or a licensed psychological examiner. I certify that the information listed above is true and correct. Date of Birth Initial Diagnosis Date Doctor or Examiner s Signature Date Telephone Number Street Address AR1000RC5 R 7/2/2018 City Taxpayer s Signature State Zip.

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