Form Ar1000-Co - Schedule Of Check-Off Contributions - State Of Arkansas
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1AR1000-CO
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STATE OF ARKANSAS
SCHEDULE OF CHECK-OFF CONTRIBUTIONS
INDIVIDUAL INCOME TAX RETURN
ATTACH AS THE SECOND PAGE OF YOUR RETURN
NAME _________________________________________________________________ SSN _____________________
SPOUSE’S NAME: _______________________________________________________ SSN: _____________________
ADDRESS ________________________________________________________________________________________
CITY _______________________________________________________ STATE _________________ ZIP _________
INSTRUCTIONS: Check the appropriate box and enter the designated amount for each check-off in the box provided. Total
your contributions and enter the amount in Box 6. Contributions are limited to whole dollar amounts only.
FOR TAXPAYERS THAT ARE DUE A REFUND: This schedule must be attached to any return claiming a check-off
contribution. Enter the amount in Box 6 on Line 60 of the AR1000/AR1000NR or Line 26 of the AR1000S. The total amount you
contribute will reduce your refund by a corresponding amount. If this schedule is not attached to your AR1000/AR1000NR/
AR1000S or if the amount in Box 6 is not entered on Line 60 of the AR1000/AR1000NR or Line 26 of the AR1000S, your
contribution will not be recognized and the amount will be refunded to you.
FOR TAXPAYERS THAT OWE ADDITIONAL TAXES: Detach this schedule and submit a separate check for the amount
of your check-off contributions. Mail to: Arkansas Individual Income Tax - Accounting Branch, P.O. Box 3628, Little Rock, AR
72203-3628
1. ARKANSAS DISASTER RELIEF PROGRAM. ....................................................... CLS 1162
$
[
] $1
[
] $5
[
] $10
[
] ____________
[
] Your Total Refund
Write in Amount
2. U.S. OLYMPIC COMMITTEE PROGRAM. ............................................................ CLS 1145
$
[
] $1
[
] $5
[
] $10
[
] ____________
[
] Your Total Refund
Write in Amount
3. ARKANSAS SCHOOL FOR THE BLIND/SCHOOL FOR THE DEAF. ............... CLS 1164
$
[
] $1
[
] $5
[
] $10
[
] ____________
[
] Your Total Refund
Write in Amount
4. BABY SHARON’S CHILDREN’S CATASTROPHIC ILLNESS PROGRAM. ..... CLS 1144
$
[
] $1
[
] $5
[
] $10
[
] ____________
[
] Your Total Refund
Write in Amount
5. ORGAN DONOR AWARENESS EDUCATION PROGRAM. ................................ CLS 1146
$
[
] $1
[
] $5
[
] $10
[
] ____________
[
] Your Total Refund
Write in Amount
6. TOTAL CHECK-OFF CONTRIBUTIONS. ...................................................................................
$
AR1000-CO (R10/03)
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