Oregon State Charitable Check-off Petition

(ALL FIELDS MUST BE FILLED OUT)

By filling out this form we the undersigned voters, request approval for The State of Oregon Chapters of the American Red Cross under the administration of the Oregon Trail Chapter of the American Red Cross to be listed in the Oregon Personal Income Tax booklet as an Oregon charity eligible to receive donations from Oregon taxpayers.

By typing your full name here you are certifying that you are a registered Oregon voter (this is required):

Today's Date: (mm/dd/yy)

Full Name:

Address of Residence *(No PO Boxes):

City and Zip Code:

Your County: Choose Your county Baker Benton Clackamas Clatsop Columbia Coos Crook Curry Deschutes Douglas Gilliam Grant Harney Hood River Jackson Jefferson Josephine Klamath Lake Lane Lincoln Linn Malheur Marion Morrow Multnomah Polk Sherman Tillamook Umatilla Union Wallowa Wasco Washington Wheeler Yamhill

*The State of Oregon requires that signature be accompanied by the address of residence and will not accept signatures with PO Boxes.