Form Tsd-3 - Request For Penalty Waiver - Georgia Department Of Revenue Page 2
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TSD-3
(Rev. 12/2011)
Form
Georgia Department of Revenue
Request for Penalty Waiver
SECTION 1
Penalty Information
L
Enter Letter ID number listed on notice (if available):
Check tax type and enter related identification number:
FEIN:
SSN:
Individual Income Tax
-
-
-
Corporate Income Tax
STN:
IFTA: GA
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IFTA Fuel Tax
TAX ID:
WTN:
-
Other
Withholding Tax
.
Enter Penalty Waiver amount:
Enter tax periods related to the requested Penalty Waiver amount:
SECTION 2
Reason for Penalty Waiver Request
In order to understand the facts and circumstances surrounding your Penalty Waiver Request , please explain why you were unable to
comply with the tax law. Use the space provided below and use additional sheets as necessary. Include any documentation that you
believe supports your Penalty Waiver Request.
SECTION 3
Taxpayer Information
Taxpayer’s First Name
Middle Initial
Last Name
Social Security Number
Spouse’s First Name (if a joint liability)
Middle Initial Last Name
Social Security Number
Business Name
Employer Identification Number
(use if penalty owed by a business)
City
State
ZIP
Taxpayer’s Address
Daytime Telephone Number
Mailing Address
City
State
ZIP
SECTION 4
Taxpayer’s Signature
Signature
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unfulfilled filing obligations with the Department, and (iii) have truthfully completed all sections of this form to
the
best of my/our knowledge and belief. I understand that to willfully prepare or present a document that is
fraudulent or false is a criminal misdemeanor under O.C.G.A. § 48-1-6.
Taxpayer’s Signature
Spouse’s Signature (if joint return)
Title (for business entity)
Date
Representative’s Name
Representative’s Signature
Telephone Number
Date
Mail this application and all attachments to the following address:
Georgia Department of Revenue
Taxpayer Services Division – Penalty Waiver
P.O. Box 105596
Atlanta, GA 30348
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