Oregon Department of Revenue
18162001010000
2020 Schedule OR-DONATE
Oregon Charitable Checkoff Donations
Submit original form—do not submit photocopy.
Office use only
Page 1 of 1, 150-101-058
(Rev. 08-13-20 ver. 01)
First name
Spouse’s first name
Social Security number (SSN)
Spouse’s SSN
Last name
Spouse’s last name
Instructions: Use this form to donate some or all of your refund to the charities listed below.
If your refund is used to pay a debt you owe or the amount you elect to donate exceeds your available refund, your donation will be
prorated based upon the amount of your available refund.
Organization name Charity code number
•
Amount of refund donated
1. Oregon Coast Aquarium .................................................................. 4 ................................................................... 1.
2. SOLVE.............................................................................................. 6 ................................................................... 2.
3. The Nature Conservancy ................................................................. 8 ................................................................... 3.
4. St. Vincent DePaul Society of Oregon ............................................. 7 ................................................................... 4.
5. Oregon Humane Society ................................................................. 10 ................................................................... 5.
6. The Salvation Army ......................................................................... 11 ................................................................... 6.
7. Doernbecher Children’s Hospital ..................................................... 9 ................................................................... 7.
8. The Oregon Veterans’ Homes ......................................................... 12 ................................................................... 8.
9. ALS Association .............................................................................. 29 ................................................................... 9.
10. Planned Parenthood of Oregon ....................................................... 13 ................................................................... 10.
11. Oregon Lions Sight & Hearing Foundation ...................................... 14 ................................................................... 11.
12. Shriners Hospitals for Children ........................................................ 15 ................................................................... 12.
13. Special Olympics Oregon ................................................................ 16 ................................................................... 13.
14. Susan G. Komen ............................................................................. 17 ................................................................... 14.
15. Oregon Military Assistance Program ............................................... 24 ................................................................... 15.
16. Oregon Historical Society ................................................................ 18 ................................................................... 16.
17. Oregon Food Bank .......................................................................... 25 ................................................................... 17.
18. Albertina Kerr Kid’s Crisis Care ....................................................... 26 ................................................................... 18.
19. American Red Cross........................................................................ 27 ................................................................... 19.
20. Cascade AIDS Project ..................................................................... 28 ................................................................... 20.
21. Veterans Suicide Prevention ............................................................ 23 ................................................................... 21.
22. Oregon Nongame Wildlife ............................................................... 19 ................................................................... 22.
23. Prevent Child Abuse ........................................................................ 20 ................................................................... 23.
24. Alzheimer’s Disease Research ........................................................ 21 ................................................................... 24.
25. Stop Domestic and Sexual Violence ............................................... 22 ................................................................... 25.
26. Habitat for Humanity ....................................................................... 1 ................................................................... 26.
27. Oregon Head Start Association ....................................................... 2 ................................................................... 27.
28. American Diabetes Association ....................................................... 3 ................................................................... 28.
29. SMART ............................................................................................ 5 ................................................................... 29.
30. Total charitable checkoff donations. Add lines 1 through 29 ............................................................................... 30.
Enter total on line 45 of Form OR-40; line 71 of Form OR-40-N; or line 70 of Form OR-40-P. This amount can’t reduce your net refund
below zero.
For more information about the charities listed above, visit www.oregon.gov/dor and search for “charitable checkoffs” or the name of
a charity.
—You must include this schedule with your Oregon income tax return to have your refund applied—
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