Form Ar1000-Co - Individual Income Tax Schedule Of Check-Off Contributions - 2012
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1
2AR1000-CO
2012
ARKANSAS INDIVIDUAL INCOME TAX
SCHEDULE OF CHECK-OFF CONTRIBUTIONS
NAME
SSN
SPOUSE’S NAME
SSN
ADDRESS
CITY
STATE
ZIP
IMPORTANT:
SEE INSTRUCTIONS ON REVERSE SIDE OF THIS FORM
1. ARKANSAS DISASTER RELIEF PROGRAM ..........................................................CLS 1162
$
[
] $1
[
] $5
[
] $10 [
] $20 [
] ____________
[
] Your Total Refund
Enter Amount
2. U.S. OLYMPIC COMMITTEE PROGRAM ............................................................... CLS 1145
$
[
] $1
[
] $5
[
] $10
[
] ____________
[
] Your Total Refund
Enter Amount
3. ARKANSAS SCHOOL FOR THE BLIND/SCHOOL FOR THE DEAF ..................CLS 1164
$
[
] $1
[
] $5
[
] $10
[
] ____________
[
] Your Total Refund
Enter Amount
4. BABY SHARON’S CHILDREN’S CATASTROPHIC ILLNESS PROGRAM ........CLS 1144
$
] Your Total Refund
[
] $1
[
] $5
[
] $10 [
] $20 [
] ____________
[
Enter Amount
5. ORGAN DONOR AWARENESS EDUCATION PROGRAM ...................................CLS 1146
$
[
] $1
[
] $5
[
] $10
[
] ____________
[
] Your Total Refund
Enter Amount
6. AREA AGENCIES ON AGING PROGRAM ...............................................................CLS 1149
$
[
] $1
[
] $5
[
] $10
[
] ____________
[
] Your Total Refund
Enter Amount
7. MILITARY FAMILY RELIEF PROGRAM ...................................................................CLS 1147
$
[
] $1
[
] $5
[
] $10 [
] $20 [
] ____________
[
] Your Total Refund
Enter Amount
8. NEWBORN UMBILICAL CORD BLOOD INITIATIVE ............................................CLS 1180
$
] Your Total Refund
[
] $1
[
] $5
[
] $10 [
] $20 [
] ____________
[
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 ..................................................
$
] Your Total Refund
[
] $25
[
] $50
[
] $100
[
] ____________
[
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 6/13/12)
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