Form Tsd-1 - Protest Of Proposed Assessment Or Refund Denial - Georgia Department Of Revenue Page 2

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TSD-1
Page 2
(Rev. 12/11)
Form
SECTION 6
Reason for Protesting Proposed Assessment
Provide a detailed explanation concerning why the Department should grant your protest to either (i) withdraw or revise the proposed
assessment or (ii) grant your request for refund. Attach additional pages, if needed, and enclose copies of any supporting documents.
Copies of canceled checks must include the front and back of the check.
SECTION 7
Signatures
All protests must be signed by the taxpayer or authorized representative. A Power of Attorney must accompany this form if
the form is signed by an authorized representative only. For those taxpayers that are corporations, limited liability
companies, or any other legal business entity, this form must be signed by the person authorized to act in the name of the
business (e.g., corporate officer, managing member, general partner, etc…).
Taxpayer’s Name
Taxpayer’s Signature
Title (for business entity)
Date
Representative’s Name
Representative’s Signature
Date
Mail this application and all attachments to the following address:
Georgia Department of Revenue
Taxpayer Services Division – Protests
P.O. Box 105596
Atlanta, GA 30348

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