Form Ar1000-Co - Schedule Of Check-Off Contributions - 2015
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1AR1000-CO
2015
ITCO151
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ARKANSAS INDIVIDUAL INCOME TAX
SCHEDULE OF CHECK-OFF CONTRIBUTIONS
NAME
SSN
SPOUSE’S NAME
SSN
ADDRESS
CITY
STATE
ZIP
SEE INSTRUCTIONS ON REVERSE SIDE OF THIS FORM
1. ARKANSAS DISASTER RELIEF PROGRAM .........................................................................
$
[
] $1
[
] $5
[
] $10 [
] $20 [
] ____________
[
] Your Total Refund
Enter Amount
2. ARKANSAS GAME AND FISH FOUNDATION ......................................................................
$
[
] $1
[
] $5
[
] $10
[
] ____________
[
] Your Total Refund
Enter Amount
3. ARKANSAS SCHOOL FOR THE BLIND/SCHOOL FOR THE DEAF .................................
$
[
] $1
[
] $5
[
] $10
[
] ____________
[
] Your Total Refund
Enter Amount
4. BABY SHARON’S CHILDREN’S CATASTROPHIC ILLNESS PROGRAM .......................
$
[
] $1
[
] $5
[
] $10 [
] $20 [
] ____________
[
] Your Total Refund
Enter Amount
5. ORGAN DONOR AWARENESS EDUCATION PROGRAM ..................................................
$
[
] $1
[
] $5
[
] $10
[
] ____________
[
] Your Total Refund
Enter Amount
6. AREA AGENCIES ON AGING PROGRAM ..............................................................................
$
[
] $1
[
] $5
[
] $10
[
] ____________
[
] Your Total Refund
Enter Amount
7. MILITARY FAMILY RELIEF PROGRAM ..................................................................................
$
[
] $1
[
] $5
[
] $10 [
] $20 [
] ____________
[
] Your Total Refund
Enter Amount
8. NEWBORN UMBILICAL CORD BLOOD INITIATIVE ...........................................................
$
[
] $1
[
] $5
[
] $10 [
] $20 [
] ____________
[
] Your Total Refund
Enter Amount
9. ARKANSAS TAX DEFERRED TUITION SAVINGS PROGRAM
IMPORTANT: To contribute to your Arkansas Tax Deferred Tuition Savings Program, you MUST enter the account
number below. You may contribute part or all of your refund to one or two accounts, provided a minimum of $25 is
contributed to each account. (You cannot send a check for this check-off.)
CHOOSE ACCOUNT TYPE:
GIFT
iShares ..................................................
$
[
] $25
[
] $50
[
] $100
[
] ____________
[
] Your Total Refund
Enter Amount
Account Number _________________________
CHOOSE ACCOUNT TYPE:
GIFT
iShares ..................................................
$
[
] $25
[
] $50
[
] $100
[
] ____________
[
] Your Total Refund
Enter Amount
Account Number _________________________
10. TOTAL CHECK-OFF CONTRIBUTIONS ..................................................................................... $
AR1000-CO (R 6/15/15)
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