Florence Unified School District No. 1 ARIZONA STATE TAX CREDIT CONTRIBUTION FORM Revised 07.31.2016

(PLEASE PRINT CLEARLY)

CONTRIBUTOR INFORMATION Date: ______________________ Contribution Amount: $_____________________ (one form per site) Taxpayer Name: _________________________________________________________________________ Mailing Address __________________________________________________________________________ City ______________________ State _______ Zip Code_______________ Phone: __________________ Taxpayer Signature: ______________________________________________________________________     

Single taxpayer or head of household tax credit allowed up to $200; Married, filing jointly, up to $400. Tax credit contributions allowed for extracurricular activities and/or character education programs. Corporate and/or business checks are not eligible. A.R.S. 43-1089(E) defines extracurricular activities as school sponsored activities that may require enrolled students to pay a fee in order to participate. The activities must supplement the school's education program. Recreational, amusement or tourist events and/or student trips are not eligible for tax credit. Tax credit donations are NON-REFUNDABLE and NON-TRANSFERABLE

CONTRIBUTION DESIGNATION Choose a location: Anthem K-8

Magma Ranch K-8

Florence High School

Circle Cross Ranch K-8

Skyline Ranch K-8

Poston Butte High School

Copper Basin K-8

San Tan Heights

San Tan Foothills High School

Florence K-8

Walker Butte K-8

Mountain Vista Academy

I wish to designate this money for: General Extracurricular Activities – Direct as needed to the location indicated above. Specific Eligible Activities - IMPORTANT: Please check with the school if you have questions about specific program eligibility. Ineligible designated activities will be directed to area of greatest need for selected school to remain tax credit eligible. Tax credit donations are NON-REFUNDABLE AND NON-TRANSFERABLE.

Contribution Amount $ $ $

Eligible Extracurricular Activity / Sport or Character Education Program

PTP Fee*

(Please circle)

Yes Yes Yes

Student’s Name (Please print clearly)

No No No

*PTP = Pay-to-Participate Fee for sports programs.

Payment Options: 1. Online payments: http://www.fusdaz.com/tax-credits 2. Site payments: Bring a completed tax form into the office and make payment using cash or credit/debit card. 3. Mail Payments: Complete tax credit form and mail your money order or cashier’s check to: Florence Unified School District Attn: Julie Cook, Finance P O Box 2850 Florence, AZ 85132

For more information, please contact your School Administrator or Julie Cook at the District Office at 520-866-3516. For assistance with our online payment system, please contact Joleen Carberry at 520-866-3507.