Form 500 Es - Individual Estimated Tax - 2004
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1500 ES
MAIL TO:
(Rev. 7/03)
Individual Estimated Tax
Georgia Department of Revenue
P.O. Box 740319
Atlanta, GA 30374-0319
2004
Telephone No. (404) 417-4480
Fiscal Year Ending__________20____
or 1-888-247-8175
Taxpayer’s SSN
Spouse’s SSN
Tax Year
Quarter
Due Date
Vendor Code
2004
N/A
NAME AND ADDRESS
If your name and address is incorrect, mark the change of address box and make changes
TYPE OF RETURN
Address Change
Individual
Fiduciary
.
$
Amount Paid
DO NOT STAPLE OR PAPER CLIP. REMOVE ALL CHECK STUBS
Page 15
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