“(1) If you are entitled to a refund, check if you wish to designate [ ] $1, [ ] $5, [ ] $10, [ ] $20, [ ] $________ (write in amount), or [ ] all refund due, of your tax refund for the Baby Sharon's Children's Catastrophic Illness Grant Program Trust Fund. Your refund will be reduced by this amount.
(2) If you owe an additional amount, check if you wish to contribute an additional [ ] $1, [ ] $5, [ ] $10, [ ] $20, [ ] $________ (write in amount) for the Baby Sharon's Children's Catastrophic Illness Grant Program Trust Fund. If you wish to make a contribution to the fund, you must enclose a separate check for the amount of your contribution, payable to the Baby Sharon's Children's Catastrophic Illness Grant Program Trust Fund.”