Form 511 - Oklahoma Resident Income Tax Return - 2012 Page 5

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2012 Form 511 - Resident Income Tax Return - Page 5
NOTE: Enclose this page ONLY if you have an amount shown on a schedule.
Name(s) shown
Your Social
on Form 511:
Security Number:
Donations from Refund
Schedule 511-G
This schedule allows you to make a donation from your refund to a variety of Oklahoma organizations. Information regarding each program, their
mission, how funds are utilized, and their mailing address are shown in Schedule 511-G Information. If you are not receiving a refund, but would like to
make a donation to one of these organizations, Schedule 511-G Information lists the mailing address to mail your donation to the organization. If you are
not receiving a refund and wish to donate to the Eastern Red Cedar Revolving Fund or the Public School Classroom Support Fund, please see line 36 or
37 of Form 511.
Place an ‘X’ in the box associated with the dollar amount you wish to have deducted from your refund and donated to that organization. Then carry that
figure over into the column at the right. When you carry your figure back to line 32 of Form 511, please list the line number of the organization to which
you donated. If you donate to more than one organization, please write a “99” in the box at line 32 of Form 511.
BACK TO PAGE 2
00
Oklahoma Wildlife Diversity Program ...............
$2
$5
$
...
1
?
1
00
Low Income Health Care Fund .........................
$2
$5
$
...
2
?
2
00
Oklahoma Breast and Cervical Cancer Fund ...
$2
$5
$
...
3
?
3
Support of Programs for Volunteers to Act
4
as Court Appointed Special Advocates
00
for Abused or Neglected Children.....................
$2
$5
$
...
?
4
00
Oklahoma Pet Overpopulation Fund ................
$2
$5
$
...
5
?
5
00
Support of the Oklahoma National Guard ........
$2
$5
$
...
6
?
6
00
Oklahoma Leukemia and Lymphoma Fund ......
$2
$5
$
...
7
?
7
Support of Programs for Regional Food Banks
8
00
in Oklahoma .....................................................
$2
$5
$
...
?
8
00
Support of Folds of Honor Scholarship Program
$2
$5
$
...
9
?
9
00
Y.M.C.A. Youth and Government Program .......
$2
$5
$
.
10
?
10
00
Multiple Sclerosis Society Fund........................
$2
$5
$
.
11
?
11
00
Support Oklahoma Honor Flights .....................
$2
$5
$
.
12
?
12
00
Eastern Red Cedar Revolving Fund .................
$2
$5
$
.
13
?
13
Support of Domestic Violence and Sexual
14
00
Assault Services ...............................................
$2
$5
$
.
?
14
00
Support of Volunteer Fire Departments ............
$2
$5
$
.
15
?
15
00
Oklahoma Lupus Revolving Fund ....................
$2
$5
$
.
16
?
16
00
Oklahoma Sports Eye Safety Program.............
$2
$5
$
.
17
?
17
00
Historic Greenwood District Music Festival Fund ..
$2
$5
$
.
18
?
18
00
Public School Classroom Support Fund ...........
$2
$5
$
.
?
19
19
00
Total donations (add lines 1-19, enter total here and on line 32 of Form 511) ..........
20
20
Schedule 511-G: Information
3- Oklahoma Breast and Cervical Cancer Fund
1- Oklahoma Wildlife Diversity Program
You may donate for the benefit of breast and cervical cancer early
The Oklahoma Wildlife Diversity Program is funded primarily by con-
cerned Oklahomans. All donations provide for a variety of projects,
detection, public education and research. Your donation will be
including research on Texas horned lizards and other rare wildlife,
placed in a fund to be used for the purpose of funding programs to
increase knowledge of breast and cervical cancer risk and prevention
wildlife observation activities, such as statewide educational work-
shops, informational brochures and posters, and management of a
and provide mammograms, pap tests and biopsies for low-income
bat cave purchased with previous program donations. If you are not
women. If you are not receiving a refund, you may still donate. Mail
your contribution to: Oklahoma State Department of Health, Breast
receiving a refund, you may still support Oklahoma wildlife by send-
ing a donation to: Wildlife Diversity Program, 1801 North Lincoln,
and Cervical Cancer Revolving Fund, 1000 NE 10th Street, Okla-
Oklahoma City, OK 73105.
homa City, OK 73152.
4- Support for Programs for Volunteers to Act as Court Appoint-
2- Low Income Health Care Fund
Oklahomans helping each other is what the Indigent (Low Income)
ed Special Advocates for Abused or Neglected Children
Health Care Fund is all about. Donations made to the fund are used
You may donate from your tax refund to support programs for volun-
to help provide medical and dental care for needy children and
teers to act as Court Appointed Special Advocates for abused or ne-
families. Every dollar you donate goes directly for health care costs.
glected children. Donations will be placed in the Income Tax Checkoff
If you are not receiving a refund, you may contribute toward indigent
Revolving Fund for Court Appointed Special Advocates. Monies will
health care by sending a donation to: Oklahoma Department of Hu-
be expended by the Office of the Attorney General for the purpose of
man Services, Revenue Processing Unit, Re: Indigent Health Care
providing grants to the Oklahoma CASA Association. If you are not
Revolving Fund, P.O. Box 248893, Oklahoma City, OK 73124.
receiving a refund, you may still donate. Mail your contribution to:
Oklahoma CASA Association, Inc., P.O. Box 54946, Oklahoma City,
OK 73154.

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