“(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 Newborn Umbilical Cord Blood Initiative. 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 Newborn Umbilical Cord Blood Initiative. If you wish to make a contribution to the program, you must enclose a separate check for the amount of your contribution, payable to the Newborn Umbilical Cord Blood Initiative.”