Georgia Form 500x - Amended Individual Income Tax Return - 2011 Page 2

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500X
Part I. - Exemptions
1.
1. Number of exemptions claimed on original return
2.
2. Number of exemptions claimed on this return
3.
3. Difference, if any
Dependents (children and other) not claimed on the original (or adjusted) return:
First Name
Last
Social Security Number
Relationship to you
If more than
three
additional
dependents,
attach a list
65 or over Blind
4. Additional Standard Deduction for Yourself and Spouse
Enter Number
[ ]
[ ]
(Check only those boxes not checked on
Yourself....................
of boxes
[ ]
original return and only if Standard Deduction is used).
[ ]
Spouse.....................
checked
Part II. - Computation of Georgia Taxable Income for part-year residents and nonresidents
GEORGIA
Income Not Taxable
Federal Income after
to Georgia
INCOME
Georgia Adjustments
COLUMN B.
COLUMN C.
COLUMN A.
.00
.00
.00
1. Wages, Salaries, Tips, Etc .....................................................
1.
.00
.00
.00
2.
2. Interest and Dividends ...........................................................
.00
.00
.00
3.
3. Business Income or (loss ......................................................
.00
.00
.00
4.
4. Other Income or (loss) ...........................................................
.00
.00
.00
5.
5. Total Income: Total Lines 1 through 4 .....................................
Adjustments to Income:
.00
.00
.00
6.
6. Total from Federal Form 1040 ................................................
.00
.00
.00
7.
7. Total Georgia Adjustments, explain in PART IV below ..........
.00
.00
.00
8.
8. Adjusted Gross Income: Line 5 plus or minus Lines 6 and 7
%
(Not to exceed 100%)
(
)
9.
9.
RATIO: Divide Line 8, Column C by Column A - Enter Percentage ................................
.00
10.
10.
Itemized or Standard Deduction ......................................................................................
.00
11.
11. Personal Exemptions ........................................................................................................
.00
12.
12. Total Deductions and Exemptions: Add Lines 10 and 11 ...............................................
.00
13.
13. Multiply Line 12 by Ratio on Line 9 and enter result ....................................................................................................
.00
14.
14. Georgia Taxable Income: Subtract Line 13 from Line 8. Enter on Line 5C on reverse side .....................................
Part III.
Disability OR retirement income exclusion
you____________________________spouse____________________________
Date of birth OR disability
you____________________________spouse____________________________
Type of disability
you____________________________spouse____________________________
Part IV.
EXPLANATION OF CHANGES
to Income, Deductions, Exemptions, and Credits. Show computations in detail.
Attach applicable schedules.
INSTRUCTIONS
1.
Attach a copy of your original and amended federal return.
2.
If the return is being amended due to a K-1, include the original and amended K-1.
3.
If you are filing an amended return to claim the low income credit, the claim must be filed by the end of the 12th month following the close of the
taxable year for which the credit may be claimed.
4.
If you want all or part of the refund applied to estimated tax, indicate this with the year and the amount on Line 19.
5.
If the return is being amended due to a W-2, include a copy of the W-2.
MAIL COMPLETED RETURN TO:
GEORGIA DEPARTMENT OF REVENUE, PROCESSING CENTER, P.O. BOX 740318, ATLANTA, GEORGIA 30374-0318
GEORGIA PUBLIC REVENUE CODE SECTION 48-2-31 STIPULATES THAT TAXES SHALL BE PAID IN LAWFUL MONEY OF
THE
UNITED STATES, FREE OF ANY EXPENSE TO THE STATE OF GEORGIA.
Page 2

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