“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 Association of Area Agencies on Aging to fund programs and activities for senior citizens. Your refund will be reduced by this amount.
If you owe an additional amount, check if you wish to contribute an additional [ ] $1, [ ] $5, [ ] $10, [ ] _______ (write in amount) for the Arkansas Association of Area Agencies on Aging to fund programs and activities for senior citizens. If you wish to make a contribution to the Arkansas Association of Area Agencies on Aging, you must enclose a separate check for the amount of your contribution payable to the Department of Finance and Administration.”