Form Ar1000Rc5 PDF Details

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QuestionAnswer
Form NameForm Ar1000Rc5
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names Overview of Arkansas Retirement Tax Friendliness

Form Preview Example

AR1000RC5

ITDD201

2020

ARKANSAS INDIVIDUAL INCOME TAX

CERTIFICATE FOR INDIVIDUALS WITH

DEVELOPMENTAL DISABILITIES

Primary’s legal name

Spouse’s legal name

Primary’s social security number

Spouse’s social security number

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Developmentally disabled dependent’s name

Social security number

Relationship to taxpayer

 

 

 

 

 

 

 

 

 

Taxpayer’s signature

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Cerebral Palsy

Intellectual Disability

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Autism

Down Syndrome

Spina i da

1. Did the developmental disability originate before the individual attained the age of 22? .............................................

2. ill the developmental disability continue or can be expected to continue inde nitely and constitute 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? ............................................

Yes

No

Yes

No

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.

Initial diagnosis date

 

 

Date of birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Doctor or examiner’s signature

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Doctor or examiner’s name

 

 

Telephone number

 

 

 

 

 

 

 

 

 

 

 

 

 

Street address

City

 

State

 

Zip

AR1000RC5 (R 06/03/2020)

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This document will need specific info to be typed in, hence you should take your time to provide precisely what is asked:

1. First of all, when filling in the Form Ar1000Rc5, start with the part with the following blanks:

Writing part 1 in Form Ar1000Rc5

2. The subsequent stage would be to complete these fields: Cerebral Palsy cidpilepsy Autism, Intellectual Disability, Did the developmental disability, Yes, cidill the developmental, a substantial impairment to the, Yes, The above individual has been, Initial diagnosis date, Date of birth, Doctor or examiners signature, and Date.

Form Ar1000Rc5 writing process shown (step 2)

3. The next step is usually straightforward - fill out all of the empty fields in Doctor or examiners name, Telephone number, Street address, City, State, Zip, and ARRC R to finish this segment.

Form Ar1000Rc5 writing process outlined (step 3)

Always be very careful when completing Zip and Doctor or examiners name, because this is where many people make a few mistakes.

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