Fillable Dependent with a Disability Exemption for the tax (Wellington City Council New Zealand)

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Dependent with a Disability Exemption for the tax (Wellington City Council New Zealand)

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Utah State Tax Commission
Dependent with a Disability Exemption for the tax year ending
_______________
.
You must obtain an authorized certification signature below in order to claim the exemption. Do not send this form with your
return. Keep this form and all related documents with your records. See instructions on reverse side.
Taxpayer's name Social Security number
Name of person/child with a disability Social Security number
Please select one of the following:
Part 1 - Dependent Child with a Disability (21 years of age or younger)
To qualify as a dependent child with a disability, all of the following conditions must be met:
1. The dependent is 21 years of age or younger;
2. The dependent is claimed as a dependent on the taxpayer’s federal individual income tax return;
3. The dependent is not the taxpayer or the taxpayer’s spouse; and
4. The dependent is:
a. an eligible student with a disability (see instructions for eligibility); OR
b. identified under Utah Department of Health guidelines as qualified for the Baby Watch Early Intervention Program for
Infants and Toddlers.
Part 2 - Dependent Adult with a Disability (18 years of age or older)
To qualify as a dependent adult with a disability, all of the following conditions must be met:
1. The dependent is 18 years of age or older;
2. The dependent is claimed as a dependent on the taxpayer’s federal individual income tax return;
3. The dependent is not the taxpayer or the taxpayer’s spouse;
4. The dependent is eligible for services under Title 62A, Chapter 5, Services for People with Disabilities; and
5. The dependent is not enrolled in an education program for students with disabilities under Utah Code §53A-15-301.
REQUIRED - Authorized Certification Signature
This form is not valid unless signed by a person authorized to certify the dependent as qualified. If you checked:
Part 1, obtain the signature of:
a. a school district or charter school representative if the dependent is an eligible student with a disability, or
b. a representative of the Utah Department of Health.
Part 2, obtain the signature of a Division of Services for People with Disabilities support coordinator, the primary care physician, or
a licensed psychologist familiar with the dependent.
Authorized certification signature (required) Date signed
X
Print name Title/Agency Telephone number
Rev. 9/15
TC-40D
Clear form
Dependent with a Disability Exemption Instructions
Do not send this form with your return. Keep this form and
all related documents with your records.
General Instructions
Taxpayers claiming an exemption for a dependent with a disability
(see Utah Code §59-10-1018) must complete a form TC-40D
each year.
Form TC-40D must be signed by an authorized person certifying
the dependent with a disability qualifies for the exemption on the
taxpayer’s Utah individual income tax return.
Dependent Child with a Disability
A “dependent child with a disability” is a person 21 years of age
or younger who:
• The taxpayer claims as a dependent on the federal
individual income tax return;
• Is not the taxpayer or the taxpayer’s spouse; and
• Is an eligible student with a disability, or identified under
guidelines of the Department of Health as qualified for
the Baby Watch Early Intervention Program for Infants
and Toddlers.
For more information and certification for an eligible student with
a disability, see below.
For more information and certification for the Baby Watch Early
Intervention Program, contact:
Utah Department of Health
Baby Watch Early Intervention Program
P.O. Box 144720
Salt Lake City, UT 84114-4720
801-273-2998 or 1-800-961-4226
utahbabywatch.org
Eligible Student with a Disability
An “eligible student with a disability” is a person who:
• Is not receiving residential services from the Division of
Services for People with Disabilities created under Utah
Code §62A-5-102 or a school established under Title
53A, Chapter 25b, Utah Schools for the Deaf and the
Blind;
• Is enrolled in an education program for students with
disabilities authorized under Utah Code §53A-15-301, or
has received a scholarship under Title 53A, Chapter 1a,
Part 7, Carson Smith Scholarships for Students with
Special Needs Act; and
• An IEP team has found to be eligible under special
education rules of the State Board of Education (Title
63G, Chapter 3, Utah Administrative Rulemaking Act) as
having a disability classified as autism, deafness,
preschool developmental delay, dual sensory impairment
(deaf/blind), hearing impairment, intellectual disability,
multi-disability, orthopedic impairment, other health
impairment, traumatic brain injury, or visual impairment.
For more information, contact the special education office of your
local school district or charter school, your local school, or:
Utah State Office of Education
250 East 500 South
P.O. Box 144200
Salt Lake City, UT 84114-4200
801-538-7500
Note: A principal or representative from the school in which the
student is enrolled is authorized to certify the student’s eligibility.
Dependent Adult with a Disability
A “dependent adult with a disability” is a person 18 years of age
or older who:
• The taxpayer claims as a dependent on the federal
individual income tax return;
• Is not the taxpayer or the taxpayer’s spouse;
• Is eligible for services under Title 62A, Chapter 5,
Services for People with Disabilities; and
• Is not enrolled in an education program for students with
disabilities authorized under Utah Code §53A-15-301.
For more information, contact:
Division of Services for People with Disabilities (DSPD)
195 North 1950 West
Salt Lake City, UT 84116
1-844-275-3773
dspd.utah.gov
Note: If a person is enrolled in DSPD services, a DSPD support
coordinator may certify the person’s eligibility. If not receiving
DSPD services, a primary care physician or licensed psycholo-
gist may certify.
_____________________
Get tax forms at tax.utah.gov/forms-pubs/forms, or by calling
801-297-6700 or 1-800-662-4335 ext. 6700 (if outside the Salt
Lake area).
If you need an accommodation under the Americans with
Disabilities Act, email taxada@utah.gov, or call 801-297-3811 or
TDD 801-297-2020. Please allow three working days for a
response.
TC-40D_i
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Dependent with a Disability Exemption for the tax (Wellington City Council New Zealand)

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Completed 19 February 2021

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