Form It-550 Claim For Refund Of Georgia Income Tax Erroneously Or Illegally Collected

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CLEAR

CLAIM FOR REFUND OF GEORGIA INCOME TAX

IT-550 (Rev. 1/13)

STATE OF GEORGIA

ERRONEOUSLY OR ILLEGALLY COLLECTED

DEPARTMENT OF REVENUE

TAXPAYER SERVICES DIVISION

Name

IMPORTANT

SEE INSTRUCTIONS ON

Street and Number

BACK PAGE FOR USES

OF THIS FORM AND

City or Town

County

State

Zip Code

FOR MAILING

ADDRESSES

Federal Employer ID Number

Georgia Withholding Number

Taxpayer’s Social Security Number

Spouse’s Social Security Number

Tax Type:

Withholding

Corporate

Individual

1. Taxable year or period for which taxes were paid:

Calendar year or period

or fiscal year ending

2. Amount of tax paid

3. Amount of tax due

4. Amount of refund claimed

Claimant believes that this claim should be allowed for the following reasons:

(A t t ac h se p a ra t e p a g es i f a d di t i on a l s p a ce i s n e ed e d .)

I ( w e) d ec l a re u nd e r t h e p e n al t i es o f p e rj u r y t h at t hi s cl a i m ( i nc l u di n g a n y a c c om p a ny i n g s c he d u le s an d st a t em e n ts ) ha s be e n e x a mi n e d

by me ( us ) an d to t he b es t of m y ( o ur ) kn o w le d g e a n d b e li e f i s tr u e a n d c o r re c t .

Date__________________ , ___________

Signed: __________________________________________

( Cl ai m m us t b e s ig n ed b y b ot h h u sb an d a nd wi fe if

________ _ __ __ _ ___________________________

a j o i n t r e t u r n w a s f i l e d . C o r p o r a t e o f f i c e r s h o u l d s t a t e h i s / h e r t i t l e . )

__________________________________________________________________________________________________________

THIS SECTION IS FOR OFFICIAL USE ONLY.

I recommend that action on this claim be taken as indicated in the following schedule.

Amount Claimed

$____________________

Amount Rejected