"Catastrophic Leave Bank Program - Dependent Child Certification Form" - Arkansas

Catastrophic Leave Bank Program - Dependent Child Certification Form is a legal document that was released by the Arkansas Department of Finance & Administration - a government authority operating within Arkansas.

Form Details:

  • Released on June 15, 2018;
  • The latest edition currently provided by the Arkansas Department of Finance & Administration;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Arkansas Department of Finance & Administration.

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Download "Catastrophic Leave Bank Program - Dependent Child Certification Form" - Arkansas

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DEPARTMENT OF FINANCE AND ADMINISTRATION - Office of Personnel Management
Catastrophic Leave Bank Program - Dependent Child Certification
Part I - To Be Completed by Employee or Employee's Designee
I hereby certify that:
Name of Child
SSN:
Date of Birth:
a. resides in my home at least 50% of the time
Yes
No
b. receives at least 50% of support from me
Yes
No
c. is a dependent child
Yes
No
d. is a dependent on my Arkansas Income Tax
Yes
No
e. if not claimed as a dependent - please explain below:
Arkansas Code §21-4-203 (4) states that "Catastrophic Illness" means a medical condition of an employee or of the
spouse or parent of the employee or of a child of the employee which may be claimed as a dependent under the
Arkansas Income Tax Act of 1929.
I authorize the Arkansas Individual Income Tax Section to verify that the above listed child is claimed as a dependent on my
Arkansas Individual Income Tax Return for the most recent tax year.
Employee's Agency
Agency Address and Fax #
SSN
Employee Signature
Date
For verification of dependent status, submit to:
Arkansas Individual Income Tax, 227 Ledbetter Building, Little Rock, AR 72201 or FAX 501-682-7691
Part II - To be completed by Arkansas Individual Income Tax Section
was
was not
I hereby certify that the above listed child
listed as a dependent child of the employee for the most
recent tax year.
Name and Title, DFA-Revenue-Individual Income Tax Section
Date
DFA-OPM Catastrophic Leave Bank Program - Dependent Child Certification (R 6/15/2018)
Print Form
Clear Form
DEPARTMENT OF FINANCE AND ADMINISTRATION - Office of Personnel Management
Catastrophic Leave Bank Program - Dependent Child Certification
Part I - To Be Completed by Employee or Employee's Designee
I hereby certify that:
Name of Child
SSN:
Date of Birth:
a. resides in my home at least 50% of the time
Yes
No
b. receives at least 50% of support from me
Yes
No
c. is a dependent child
Yes
No
d. is a dependent on my Arkansas Income Tax
Yes
No
e. if not claimed as a dependent - please explain below:
Arkansas Code §21-4-203 (4) states that "Catastrophic Illness" means a medical condition of an employee or of the
spouse or parent of the employee or of a child of the employee which may be claimed as a dependent under the
Arkansas Income Tax Act of 1929.
I authorize the Arkansas Individual Income Tax Section to verify that the above listed child is claimed as a dependent on my
Arkansas Individual Income Tax Return for the most recent tax year.
Employee's Agency
Agency Address and Fax #
SSN
Employee Signature
Date
For verification of dependent status, submit to:
Arkansas Individual Income Tax, 227 Ledbetter Building, Little Rock, AR 72201 or FAX 501-682-7691
Part II - To be completed by Arkansas Individual Income Tax Section
was
was not
I hereby certify that the above listed child
listed as a dependent child of the employee for the most
recent tax year.
Name and Title, DFA-Revenue-Individual Income Tax Section
Date
DFA-OPM Catastrophic Leave Bank Program - Dependent Child Certification (R 6/15/2018)
Print Form
Clear Form