“(A) If you are entitled to a refund, check if you wish to designate [ ] $1, [ ] $5, [ ] $10, [ ] _______ (write in amount) or [ ] all refund due of your tax refund for the Arkansas School for the Blind and the Arkansas School for the Deaf. Your refund will be reduced by this amount.
(B) If you owe an additional amount, check if you wish to contribute an additional [ ] $1, [ ] $5, [ ] $10, [ ] _______ (write in amount) for the Arkansas School for the Blind and the Arkansas School for the Deaf. If you wish to make a contribution to the schools, you must enclose a separate check for the amount of your contribution payable to the Department of Finance and Administration.”