Georgia Form 500 - Individual Income Tax Return - 2004

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500

Georgia Form

(Rev. 6/04)

Clear

Individual Income Tax Return

Georgia Department of Revenue

2004

DO NOT USE STAPLES OR PAPER CLIPS

(Approved web version)

Fill in circle if you DO NOT want a booklet next yea

DEPARTMENT USE ONLY

DEL

EXT

Fiscal Year Beginning

Fiscal Year Ending

Your First Name

Initial

Your Social Security Number

Your Last Name

Suffix

Spouse’s First Name

Initial

Spouse’s Social Security Number

Spouse’s Last Name

Suffix

(Check if Address has Changed)

Address

(Use 2nd address line for Apt, Suite, Unit or Bldg number)

City

State

Zip Code

Residency

Country (If Foreign)

Status

4. Enter your Residency Status with the appropriate number ..........................................................................................................

1. Full-Year Resident

2. Part-Year Resident from

3. Nonresident

Part-Year Residents and Nonresidents must omit Lines 9 thru 14 and use Schedule 3 of Form 500, page 4

Filing Status

5. Enter Filing Status with appropriate letter (Must be the same status used on your Federal Return) ............................................

A. Single

C. Married filing separate (Spouse’s social security number must be entered above)

B. Married filing joint

D. Head of Household or Qualifying Widow(er)

6. Number of exemptions (Check appropriate box(es) and enter total in 6c.)

6a. Yourself

6b. Spouse

6c.

Dependents- (If you have more than 3 dependents, attach a list of additional dependents)

First Name

Last Name

Dependent’s SSN

Relationship to You

7a. Number of Dependents (DO NOT include yourself or your spouse) .........................................................................................

7a.

7b. Add Lines 6c and 7a. Enter total .........................................................................................................................

7b.

If amount on line 8, 9, 10, or 13 is negative, fill in circle. Example:

8. Federal adjusted gross income (From Federal Form 1040, 1040A or 1040 EZ) ........................

(Do not use FEDERAL TAXABLE INCOME)

If the amount on Line 8 is $40,000 or more, or your gross income is less than your W-2s, you must enclose a copy of your

Federal Form 1040 pages 1 and 2. Do not enclose other Federal Schedules

9. Adjustments from Schedule 1

(See instructions on Page 7, Line 9) ................................................

10. Georgia adjusted gross income

(Net total of Line 8 and Line 9) .......................................................

10.

11. Standard Deduction