Please fill out the following information if you would ...



I authorize the Chandler Unified School District to deduct a total of $________________ as a contribution to the public school system to be used for extracurricular tax credit. The amount cannot exceed $400.00 per calendar year if filing status is Married, Filing Joint return; $200.00 per calendar year if filing status is Single or Head of Household; and $200.00 per calendar year if filing status is Married, Filing Separate return. The deduction will be distributed evenly over 20 pay periods as follows: Beginning January through May and August through December. A tax credit receipt will be sent to you by January 31. By law the donation must be used for extracurricular activities, ARS 43-1089.01. The donation must be assigned to a site, and a specific area, i.e. band, field trip, etc., may be noted but is not necessary. Please, print in black ink. If your spouse also works in the district, please complete spousal information.

PLEASE RETURN THIS FORM TO PAYROLL.

DONOR’S LAST NAME: ____________________________________ DONOR’S FIRST NAME: ___________________________________

SITE OF EMPLOYMENT: ___________________________________ SPOUSE’S NAME: ________________________________________

DONOR’S SOCIAL SECURITY NUMBER: _______________________________________________________________________________

DONOR’S SIGNATURE: _________________________________________________________DATE:_______________________________

I would like my contribution to support the following school(s):

$__________ Andersen Elementary

$__________ Auxier Elementary

$__________ Basha Elementary

$__________ Bologna Elementary

$__________ Carlson Elementary

$__________ Conley Elementary

$__________ CTA-Freedom Campus

$__________ CTA-Goodman Campus

$__________ CTA-Humphrey Elementary

$__________ CTA-Independence Campus

$__________ CTA-Liberty Campus

$__________ Elite Performance Academy

$__________ Frye Elementary

$__________ Fulton Elementary

$__________ Galveston Elementary

$__________ Haley Elementary

$__________ Hancock Elementary

$__________ Hartford Sylvia Encinas Elementary

$__________ Hull Elementary

$__________ Jacobson Elementary

$__________ Knox Elementary

$__________ Navarrete Elementary

$__________ Patterson Elementary

$__________ Riggs Elementary

$__________ Ryan Elementary

$__________ Sanborn Elementary

$__________ San Marcos Elementary

$__________ Santan Elementary

$__________ Shumway Elementary

$__________ Tarwater Elementary

$__________ Weinberg Elementary

$__________ Andersen Junior High

$__________ AZ College Prep-Oakland

$__________ Bogle Junior High

$__________ Payne Junior High

$__________ Santan Junior High

$__________ Willis Junior High

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$__________ AZ College Prep - Erie

$__________ Basha High

$__________ Casteel High

$__________ Chandler High

$__________ Hamilton High

$__________ Perry High

$__________ Hill Learning Academy

$__________ Chandler Early College

Below list any specific activities per site: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PAYROLL USE ONLY: ________________________ / ________________________ = ____________________

EFFECTIVE DATE: ____________________________

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