Form 4642 - Michigan Voluntary Contributions Schedule - 2013
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Michigan Department of Treasury
4642 (Rev. 07-13)
2013 MICHIGAN Voluntary Contributions Schedule
Issued under authority of Public Act 281 of 1967.
INSTRUCTIONS: Use this schedule to make a donation from your refund to any of the organizations listed below. If you are
not receiving a refund, your donation will increase your tax due. Check the box associated with the dollar amount you wish to
contribute in columns A or B or enter a specific dollar amount greater than $10 in the space provided in column C. Enter the total
of your contribution for each line in column D. For detailed descriptions of each fund, see the reverse side of this form. Attach
completed form to Form MI-1040.
1 4
0123456789
Attachment 18
Type or print in blue or black ink. Print numbers like this:
- NOT like this:
Filer’s Social Security No. (Example: 123-45-6789)
Filer’s First Name
M.I.
Last Name
If a Joint Return, Spouse’s First Name
M.I.
Last Name
Spouse’s Social Security No. (Example: 123-45-6789)
A.
B.
C. Other Amount
D. Total Contribution
(greater than $10)
1. ALS of Michigan (“Lou Gehrig’s Disease”)
$5
$10
$
00
00
Fund. ..........................................................
1.
................
$5
$10
$
00
00
2.
Alzheimer’s Association of Michigan. ........
2.
................
$5
$10
3. AMBER Alert Fund of Michigan. ................
$
00
00
3.
................
$5
$10
$
00
00
4.
Animal Welfare Fund ..................................
4.
.................
$5
$10
5.
$
5.
00
00
Children of Veterans Tuition Grant Program
.................
6. Children’s Trust Fund -
$5
$10
$
00
00
Preventing Child Abuse in Michigan ...........
6.
.................
$5
$10
$
00
00
7. Girl Scouts of Michigan Fund .....................
7.
.................
$5
$10
$
00
00
8. Military Family Relief Fund .........................
8.
.................
$5
$10
$
00
00
9. Special Olympics Michigan.........................
9.
.................
$5
$10
$
00
00
10. United Way Fund ........................................
10.
.................
11. Add column D, lines 1 through 10. Enter total of column D here and carry amount to your MI-1040, line 22 ......
00
11.
This form must be attached to your MI-1040 to ensure your contributions are properly credited to the designated fund(s). Visit
for details on voluntary contribution funds.
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