Georgia Form 500 - Individual Income Tax Return - 2004 Page 2
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500
Georgia Form
Page 2
Individual Income Tax Return
Georgia Department of Revenue
2004
Your Social Security Number
13. Subtract either Line 11c or Line 12 from Line 10; enter balance .......................................
13.
.
14a. Number on Line 6c___multiplied by $2,700
14a.
.
14b. Number on Line 7a___multiplied by $3,000
14b.
.
14c. Add Lines 14a. and 14b. Enter total ................................................................................
14c.
.
15. Georgia taxable income (
15.
.
Line 13 less Line 14c or Schedule 3, Line 14) .......................................
16. Tax (Use Tax Table on Pages 17-19) ...............................................................................
16.
.
17. Credits from Schedule 2, Page 3 (
) ............
17.
.
Enter total but not more than the amount on Line 16
18. Balance (Line 16 less Line 17) if zero or less than zero, enter zero ..................................
18.
.
19. Georgia Income Tax Withheld (
)
19.
.
Enter Tax Withheld Only and enclose withholding statements
20. Estimated Tax for 2004 and Form IT-560 ...................................................................
20.
.
21. Low Income Credit (
) 21a.
21b.
..............
21c.
.
See worksheet on Page 11
22. Department Use Only
DO NOT WRITE IN THIS BOX
22.
.
23. Total prepayment credits (Add Lines 19, 20 and 21c) ...................................................
23.
.
24. If Line 18 exceeds Line 23 enter BALANCE DUE STATE ................................................
24.
.
25. If Line 23 exceeds Line 18 enter OVERPAYMENT amount .............................................
25.
.
26. Amount to be credited to 2005 ESTIMATED TAX .....................................................
26.
.
27. Georgia Wildlife Conservation Fund (No gift of less than $1.00) ......................................
27.
.
28. Georgia Children and Elderly Fund (No gift of less than $1.00) .......................................
28.
.
29. Georgia Cancer Research Fund (No gift of less than $1.00) ........................................
29.
.
30. Georgia Greenspace Trust Fund (No gift of less than $1.00) ........................................
30.
.
31. Form 500 UET (Estimated tax penalty) .........................................................................
31.
.
32. (If you owe) Add Lines 24, 27, 28, 29, 30 and 31 THIS IS THE AMOUNT YOU OWE
32.
.
Complete and mail Form 525-TV with your tax return and check or money order payable to: GEORGIA DEPARTMENT OF REVENUE
See page 25 in the 511 booklet for information about how to order Form 525-TV or
visit
DO NOT STAPLE OR PAPER CLIP YOUR CHECK, W-2’S OR TAX RETURN. ENCLOSE ALL ITEMS IN THE RETURN ENVELOPE.
33. (If you are due a refund) Subtract the sum of Lines 26 thru Line 31from Line 25
THIS IS YOUR REFUND ...............................................................................................
33.
.
REFUNDS TO:
PAYMENTS AND TAX RETURNS TO:
GEORGIA DEPARTMENT OF REVENUE
GEORGIA DEPARTMENT OF REVENUE
PROCESSING CENTER
PROCESSING CENTER
P.O. BOX 740380
P.O. BOX 740399
ATLANTA, GEORGIA 30374-0380
ATLANTA, GEORGIA 30374-0399
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.
Under penalty of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief it is true, correct
and complete. Declaration of preparer (other than taxpayer) is based on all information of which the preparer has any knowledge.
Check the box
to authorize the
Georgia
X ___________________________________
____________________
_____________________
Department of
Taxpayer’s Signature
Date
Daytime Phone Number
Revenue to
(Check box if deceased
)
discuss the
contents of this
tax return with
the preparer
___________________________________
____________________
named below.
X Spouse’s Signature(
)
Date
Check box if deceased
X ___________________________________
____________________
__________________
_______________
Name of Preparer if other than taxpayer
Preparer’s FEIN
Preparer’s SSN/PTIN
Phone Number
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