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

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IT -550 (REV. 4-94)
STATE
OF GEORGIA
CLAIMFOR REFUND OF GEORGIA INCOMETAX
DEPARTMENT
OF REVENUE
ERRONEOUSLYOR ILLEGALLYCOLLECTED
INCOMETAXDIVISION
NAME
(PRINT
OR TYPE)
IMPORTANT
This claim must b efiled with
the
Department
ofRevenue
Georgia Income TaxDivision
P.O.Box 740385
Atlanta, Georgia 3 03744385
STREETANDNIJMBER
I
CITY
OR
TOWN
COUNTY
STATE
ZIP CODE
FEDERAL
EMPLOYER
ID.NO.
GA.WIHOLD.TAX
ACCT
NO
I
TAXPAYERS
S.S.
NUMBER
SPOUSE
S.S. N UMBER
1. Taxable y earfor
which
taxeswerepaid:
Calendar year
orfiscal y ear
2. Amount of
tax
paid
3. Amount of
tax
due
4. Amount ofrefund claimed
ending
, 19
$
Claimant believes t hatthisclaim shouldbe allowed f orthefollowing reasons
$
$
(Usereverse sideor attachseparatepagesifadditional spaceis needed)
I(we)declareunderthe penalties o fperjury t hatthisclaim (including anyaccompanying schedules and
examined b yme(us)andto the bestof my(our)knowledge andbelief i strueandcorrect.
statements) has been
Date
, 19
Signed:
(Claim mustbe signedbybothhusbandandwifeis a joint
return wasfiled.Corporate o fficer s houldstatehistitle. )
Taxpayer: Donotwritebelow thisline,
I RECOMMEND
THAT ACTION ONTHIS CLAIM BETAKEN ASINDICATED INTHEFOLLOWING SCHEDULE:
Amt Claimed
$
Amt Rejected
$
Amt Allowed
$
Interest
From
To
$
Total
$
(Exam Agt.)
Approved b y
(App.Agt.)
Basedonthefactsas statedinthisclaim andonthe certificate ofthe Examining and
refund be issued, o r denied.
Approving Agents, a s above,
it
is directed t hat
DEPARTMENT
OFREVENUE, INCOME T AX DIVISION
Dated
, 19
By

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