Michigan Voluntary Contributions Schedule

Voluntary Contributions Schedule
4642, 2023  Michigan Voluntary Contributions Schedule and Anatomical Gift Donor Registry
Reset Form
Michigan Department of Treasury
4642 (Rev. 09-23)

Issued under authority of Public Act 281 of 1967, as amended.

2023 MICHIGAN Voluntary Contributions and Anatomical Gift Donor Registry
Schedule
Type or print in blue or black ink.

Attachment 18

Filer’s First Name

M.I.

Last Name

Filer’s Full Social Security No. (Example: 123-45-6789)

If a Joint Return, Spouse’s First Name

M.I.

Last Name

Spouse’s Full Social Security No. (Example: 123-45-6789)

Voluntary Contributions
Use this schedule to make a donation from your refund to any of the organizations listed below. If you are not receiving a refund,
your donation will increase your tax due. Check the box associated with the dollar amount you wish to contribute in columns A or B
or enter a specific dollar amount greater than $10 in the space provided in column C. Enter the total of your contribution for each
line in column D. For detailed descriptions of each fund, see the reverse side of this form. This form must be included with your
MI-1040 to ensure your contributions are properly credited to the designated fund(s).
A.

B.

C. Other Amount

D. Total Contribution

(greater than $10)

1.

American Red Cross Michigan Fund..........

$5

$10

$

00

.................

1.

00

2.

Animal Welfare Fund ...................................

$5

$10

$

00

.................

2.

00

3.

Children Trust Michigan - Prevent Child
Abuse Michigan ...........................................

$5

$10

$

00

.................

3.

00

4.

Military Family Relief Fund ..........................

$5

$10

$

00

.................

4.

00

5.

United Way Fund.........................................

$5

$10

$

00

.................

5.

00

6.

Add column D, lines 1 through 5. Enter total of column D here and carry amount to your MI-1040, line 21........

6.

00

Anatomical Gift Donor Registry Schedule

An individual taxpayer willing to participate in the anatomical gift donor registry must complete this schedule and submit it with the
taxpayer’s state income tax return (MI-1040). Treasury will forward the information to the Michigan Department of State to be added
to the registry. More information regarding this program is included in the instructions.
Please indicate below if the filer and/or spouse is willing, under the Michigan Public Health Code, to participate in the anatomical gift
donor registry program and make an anatomical gift in the event of death.
Filer’s Date of Birth (mm-dd-yyyy)

a.

Check here if the filer is willing to participate in the anatomical gift donor registry..................................
Spouse’s Date of Birth (mm-dd-yyyy)

b.

+ 0000

Check here if the spouse is willing to participate in the anatomical gift donor registry............................

2023 82 01 27 0

2023 Form 4642, Page 2

Instructions for Form 4642, Voluntary Contributions and Anatomical Gift Donor
Registry Schedule
Voluntary Contributions
Michigan taxpayers can contribute $5, $10, or more to any
of the following funds on the Voluntary Contributions and
Anatomical Gift Donor Registry Schedule (Form 4642).
Contributions to these funds will increase your tax
liability or reduce your refund.

American Red Cross Michigan Fund
The American Red Cross is always there for you and your
community, helping to alleviate suffering caused by disasters
big and small. The Red Cross shelters, and provides emotional
support to Michigan residents and beyond; supplies about 40
percent of the nation’s blood; teaches skills that save lives;
provides international humanitarian aid; and supports military
members and their families. By mobilizing the power of
volunteers and the generosity of donors, the Red Cross responds
to more than 60,000 disasters annually. In Michigan, last year
more than 6,000 volunteers logged more than 200,000 hours
assisting others. On average 91 cents of every dollar the Red
Cross spends is invested in humanitarian services.
Animal Welfare Fund
The outside world can be a harsh, scary place for homeless pets.
And throughout Michigan, small towns and big cities alike
struggle to find the resources they need to provide medical care
to the animals they rescue. Through the Animal Welfare Fund,
the Michigan Department of Agriculture and Rural Development
provides grants to Michigan’s registered animal shelters for
spay/neuter and care programs for shelter dogs and cats up for
adoption. Grants also help support many local anti-cruelty and
animal care programs around the state. Shelters also use grant
monies from your generous donations to help care for animals
seized as part of animal cruelty and hoarding cases.
Children Trust Michigan - Prevent Child Abuse
Michigan
We help our prevention partners share supportive resources with
their community. These resources help prevent child abuse and
neglect. Your support has funded nearly 22,000 community
education sessions alone. This means over 176,000 Michigan
children were helped. We help with countless programs within
each community across the state. Our partners are ensuring that
our Michigan children grow up in a safe, nurturing environment,
allowing them to reach their full potential. Through your
generosity over the years, we now reach all 83 counties with over
100 programs. Each checked box here has a significant impact
on our mission. Thank you.
Military Family Relief Fund
The Military Family Relief Fund provides grants to
qualifying families of military members in either the
Michigan National Guard or Reserves who are called
to active duty as a result of the national response to the
September 11, 2001 terrorist attacks or a national emergency.

United Way Fund
United Way fights for the health, education, and financial
stability of every person in every community. By
contributing to the United Way Fund, you’re insuring that
your dollars stay local and work to improve the lives of
individuals and families in your community by providing
for basic needs, including, but not limited to, food, clothing,
and shelter. United Way’s greatest strength is understanding
the needs of local communities – but we’re more than just a
fundraiser. We mobilize thousands of volunteers, donors, and
advocates across your community and the State of Michigan
to help change lives through service, collaboration, and
impact. Come join us and help Michigan Live United.

Anatomical Gift Donor Registry Schedule
Registering as an organ donor is an important step for
anyone who decides to help others through the gift of organ,
eye, and tissue donation. Anyone is a potential organ donor
regardless of age or medical conditions. An organ donor can
save up to eight lives and a tissue donor can heal up to 125
people. As an organ donor, your gift will be used to help
others through transplantation, therapy, research and/or
education. After registering, you will receive a donor heart
sticker for your Michigan driver’s license or state ID.
The Michigan Organ Donor Registry is a confidential
database of residents who wish to be organ, eye, and
tissue donors after death. Individuals who are already on
the registry do not need to complete the donor registry
schedule. To remove your name, contact the Michigan
Department of State at www.michigan.gov/sos.
For more information, contact the Gift of Life Michigan at
1-866-500-5801 or www.giftoflifemichigan.org or 3861
Research Park Drive, Ann Arbor, MI 48108.
Note: Treasury does not maintain a record of any
individual’s registry status.