PerryHigh School

Chandler Unified School District

Extra Curricular Activity Tax Credit Contribution Response Form

Complete this form and return the completed form with your contribution to:

Chandler Unified School District

C/O Tax Credits

1525 W. Frye Road Chandler, AZ 85224 To contribute online navigate to:

http://chandler.mytechsupport.com/eca

First Name_____________ __ __ ____ Last Name___ _____ _____ ____ __ Phone____________ ____

Street Address______________ ___________ City________________________ State ________ ZIP _______________

Please direct my contribution as needed

Please direct my contribution to one or more of the following schools (Contributions should equal the total contribution noted above):

$________ Andersen Elementary $________ Hartford Sylvia Encinas Elementary $________ Andersen Jr High

$________ Basha Elementary $________ Hull Elementary $________ Bogle Jr High

$________ Bologna Elementary $________ Humphrey Elementary $________ Hamilton Preparatory

$________ Conley Elementary $________ Jacobson Elementary $________ Payne Jr High

$________ CTA - Freedom Campus $________ Knox Elementary $________ Santan Jr High

$________ CTA - Goodman Campus $________ Navarrete Elementary $________ Willis Jr High

$________ CTA - Independence Campus $________ Patterson Elementary

$________ CTA - Liberty Campus $________ Riggs Elementary $________ Basha High

$________ Erie Elementary $________ Ryan Elementary $________ Chandler High

$________ Frye Elementary $________ Sanborn Elementary $________ Hamilton High

$________ Fulton Elementary $________ San Marcos Elementary $___XX___ Perry High

$________ Galveston Elementary $________ Santan Elementary

$________ Haley Elementary $________ Shumway Elementary $________ Pathways Learning Center

$________ Hancock Elementary $________ Tarwater Elementary $________ Chandler Early College

$________ Weinberg Elementary

This contribution is eligible for the Arizona State income tax credit as allowed by ARS § 43-1089.01. Up to $200 per individual and up to $400 for married couples filing jointly can be claimed on personal income taxes. An official receipt will be mailed to the address provided by January 31. Contributions are non-refundable by the Chandler Unified School District. Please consult your personal tax advisor to determine the application of the credit.

Visa Card Number: ______________________________ ___ MasterCard Expiration: _____ ________

Discover Signature: __________________ _______ _______

Name (As it appears on card):_____________________ _______________

Credit Card Billing Address: Use Contributor Address Above Use Address Below

Street Address__________________ _______ City ___________________

State__ ____ ZIP _______ ______

Cash

Check

Money Order

Payable to:

Chandler Unified School District

Contributor Information

Method of Payment

Total Contribution Amount: $__________________________

Contribution Designation

I wish to designate this money for (Optional): General Extracurricular Activities – direct as needed Specific Eligible Activities:

$________ _________________________________________________________________________________________________

$________ _________________________________________________________________________________________________

$________ _________________________________________________________________________________________________

$________ _________________________________________________________________________________________________

Specific Student

Student’s First Name:______________________________ Student’s Last Name:____________________________________________

For Chandler Unified School District Use Only

Received By:____________________________________ Total Received:_____________________ Date:______________________