Georgia Form 500 - Individual Income Tax Return - 2004 Page 3
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500
Georgia Form
Page 3
Individual Income Tax Return
Georgia Department of Revenue
2004
Your Social Security Number
SCHEDULE 1 ADJUSTMENTS TO INCOME BASED ON GEORGIA LAW
(see Pages 7 and 8 of instructions)
ADDITIONS TO INCOME
1. Interest on Non-Georgia Municipal and State Bonds ...............................................................
1.
.
2. Lump Sum Distributions ..........................................................................................................
2.
.
3. Other (specify)
...............................
3.
.
4. Total Additions
...............................................................................
4.
.
(enter sum of Lines 1-3 here)
SUBTRACTION FROM INCOME
5. Retirement Income Exclusion (
)
See Retirement Income Exclusion Worksheet, Page 12
a. Self: Date of Birth
Type of Disability:
5a.
.
Date of Disability:
b. Spouse: Date of Birth
Type of Disability:
5b.
.
Date of Disability:
6. Social Security Benefits
........................................................
6.
.
(Taxable portion from Federal return)
7. Railroad Retirement Benefits
................................................
7.
.
(Taxable portion from Federal return)
8. Interest on United States Obligations (See
) ..............................................
8.
.
instructions, Page 7
9. Other
...............................
9.
.
(specify)
10. Total Subtractions
........................................................................... 10.
.
(enter sum of Lines 5-9 here)
11. Net Adjustments
................. 11.
.
(Line 4 less Line 10. Enter Net Total here and on Line 9 of Page 1)(+ or -)
SCHEDULE 2 CREDITS FOR LINE 17, PAGE 2
1. Other State(s) Tax Credit
) ................................................................
1.
.
(see worksheet on Page 11
2. Low and Zero Emission Vehicle Credit ....................................................................................
2.
.
3. Credits from Form IND-CR (
Rural Physicians Credit, Disabled Person Home Purchase or
Retrofit Credit, Driver Education Credit, Disaster Assistance Credit and
3.
.
Qualified Caregiving Expense Credit) ..........................................................................................................
4. Other Credits (specify)
..................
4.
.
Pass Through Credits from Ownership of Sole Proprietor, S Corp., LLC or Partnership Interest
You must list the appropriate Credit Type Code in the space provided. List the percentage of credit received in the % column. If you claim more than five
credits, enclose a schedule. Enter the schedule total on Line 10. See Pages 23-24 for a list of available credits and their applicable codes.
Credit Type
Company Name
FEIN
%
Credit Claimed
Unused Credit
Code
on this Return
5.
5.
.
.
6.
6.
.
.
7.
7.
.
.
8.
8.
.
.
9.
9.
.
.
10. Enter the total from enclosed schedule(s) .................................. 10.
.
.
11. Enter the total of Lines 1 thru 10 here and on Line 17, Page 2
11.
.
.
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