Georgia Form 500x - Amended Individual Income Tax Return - 2011
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500X
Georgia Department of Revenue
Georgia Form
(Rev. 2/11)
Processing Center
Amended Individual IncomeTax Return
P.O. Box 740318
Atlanta, Georgia 30374-0318
YOUR FIRST NAME
MI
YOUR SOCIAL SECURITY NUMBER
YOUR LAST NAME
SUFFIX
SPOUSE’S FIRST NAME
MI
SPOUSE’S SOCIAL SECURITY NUMBER
LAST NAME
SUFFIX
ADDRESS (NUMBER AND STREET or P.O. BOX) (Use 2nd address line for Apt., Suite or Building Number)
CHECK IF ADDRESS HAS CHANGED
DEPARTMENT USE ONLY
CITY
STATE
ZIP CODE
(COUNTRY IF FOREIGN)
Married Filing Separarely
Head of Household or Qualifying Widow(er)
Single
Married Filing Jointly
Filing
[ ]
[ ]
[ ]
[ ]
On This Return.............
Status
Claimed
Note: You cannot change from Married filing jointly to Married filing separately after the due date of the return.
Residency
[ ]
Nonresident
[ ]
[ ]
On This Return..............
Full Year Resident
Part Year Resident From_________To_________
Was a Federal Amended Return Filed? [ ] Yes
[ ] No
If YES, Please Attach Copy.
A
B
C
Calendar Year ________________ or Fiscal Year Ending _________________
Net Change Increase
As originally reported
Correct Amount
or Decrease
or as adjusted
1.
Federal Adjusted Gross Income (from Form 1040).
.00
.00
.00
1.
2.
Total Income (Georgia adjusted gross income) Form 500.
2.
.00
.00
.00
Explain any changes on Page 2.
Standard or Itemized Deductions.
3.
.00
.00
.00
3.
Exemptions. If changing fill in Part 1 and Part IV of Page 2.
4.
4.
.00
.00
.00
5 .
Taxable Income. Subtract Lines 3 and 4 from Line 2.
.00
.00
.00
5.
6.
Total tax
.00
.00
.00
6.
Georgia Income Tax Withheld
.00
.00
.00
7.
7.
.00
.00
.00
8.
8.
Other Credits
.00
.00
.00
9.
Estimated Tax Payments: Georgia Form 500
9.
.00
10. Amount paid with original return, plus additional payments made after it was filed.
10.
11. Total of Lines 7 through 10, Column C
.00
11.
12. Overpayment,
.00
if any, shown on original return: Georgia Form 500
12.
.00
13. Subtract
Line 12 from Line 11 and enter result
13.
14. If Line 6,
Column C is more than Line 13, subtract Line 13 from Line 6, enter Balance Due.
14.
.00
15. Add interest (1% per month from the due date)
.00
15.
16. Late pay penalty (1/2 of 1% per month from the due date)
16.
.00
.00
17. Total of Lines 14, 15 and 16. Pay in full with this Return
17.
18.
.00
If Line 6, Column C is less than Line13, subtract Line 6 from Line 13; enter refund to be received.
18.
19. Amount to be credited to Estimated Tax; Year ___________
.00
Amount
19.
Under penalties of perjury, I declare that I have filed an original return and that I have examined this amended return, including accompanying schedules and statements, and
to the best of my knowledge and belief this amended return is true, correct, and complete.
Sign Here ___________________________________
Your Signature
Date
Spouse’s Signature
Date
Signature of preparer other than taxpayer, based on all information of which s/he has any knowledge
Date
ID number of preparer
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