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Michigan Department of Treasury                                                     Issued under authority of Public Act 281 of 1967, as amended. 
4642 (Rev. 03-21) 

2021 MICHIGAN Voluntary Contributions Schedule 

INSTRUCTIONS: 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. Include 
with Form MI-1040. 

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) 

                                                                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’s Trust Fund - 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 22 ........ 6.                    00

This form must be included with your MI-1040 to ensure your contributions are properly credited to the designated fund(s). 

+ 0000 2021 82 01 27 4 

2021 Form 4642, Page 2 

            Instructions for Form 4642, Voluntary Contributions Schedule 
Michigan taxpayers can contribute $5, $10, or more to any of the following funds on the Voluntary Contributions Schedule  (Form  
4642).  Contributions to these funds will increase your tax liability or reduce your refund. 
American Red Cross Michigan Fund                                          Military Family Relief Fund 
The American Red Cross is always there for you and your                   The  Military  Family  Relief  Fund  provides  grants  to  
community,  helping  to  alleviate  suffering  caused  by  disasters      qualifying  families  of  military  members  in  either  the  
big and small. The Red Cross shelters, and provides emotional             Michigan  National  Guard  or  Reserves  who  are  called  
support  to  Michigan  residents  and  beyond;  supplies  about  40       to active duty as a result of the national response to the  
percent  of  the  nation’s  blood;  teaches  skills  that  save  lives;   September 11, 2001 terrorist attacks. 
provides  international  humanitarian  aid;  and  supports  military  
members  and  their  families.  By  mobilizing  the  power  of            United Way Fund 
volunteers and the generosity of donors, the Red Cross responds           United  Way  fights  for  the  health,  education,  and  financial  
to more than 60,000 disasters annually. In Michigan, last year            stability  of  every  person  in  every  community.  By  
more  than  6,000  volunteers  logged  more  than  200,000  hours         contributing  to  the  United  Way  Fund,  you’re  insuring  that  
assisting  others.  On  average  91  cents  of  every  dollar  the  Red   your  dollars  stay  local  and  work  to  improve  the  lives  of  
Cross spends is invested in humanitarian services.                        individuals  and  families  in  your  community  by  providing  
                                                                          for basic needs, including, but not limited to, food, clothing,  
Animal Welfare Fund                                                       and shelter. United Way’s greatest strength is understanding  
The outside world can be a harsh, scary place for homeless pets.          the needs of local communities – but we’re more than just a  
And  throughout  Michigan,  small  towns  and  big  cities  alike         fundraiser. We mobilize thousands of volunteers, donors, and  
struggle to find the resources they need to provide medical care          advocates across your community and the state of Michigan  
to the animals they rescue. Through the Animal Welfare Fund,              to  help  change  lives  through  service,  collaboration,  and  
the Michigan Department of Agriculture and Rural Development              impact. Come join us and help Michigan Live United.  
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’s Trust Fund - Prevent Child Abuse 
Michigan 
The Children’s Trust Fund (CTF) supports services throughout  
Michigan to prevent child abuse and neglect. CTF funds home  
visitation  services;  respite  care;  services  for  families  with  
incarcerated  family  members;  and  parenting  education  and  
support. CTF supports a statewide network of local Child Abuse  
and  Neglect  Prevention  Councils.  Examples  of  local  Council  
work  are  teaching  professionals  about  mandated  reporting;  
teaching  parents  and  caregivers  about  infant  head  trauma  
prevention and infant safe sleep practices; and establishing baby  
pantries to provide diapers, formula, and clothing. In the coming  
year,  CTF  and  its  local  Councils  will  lead  statewide  efforts   to
build local responses to the opioid crisis.