Georgia Form 500 - Individual Income Tax Return - 2011

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500

Georgia Form

Fiscal Year

(Rev. 9/11)

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Individual Income Tax Return

Georgia Department of Revenue

Fiscal Year

2011

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(Approved web version)

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YOUR FIRST NAME

YOUR SOCIAL SECURITY NUMBER

Page

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LAST NAME

SUFFIX

Special Program Code

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See Tax Booklet on Page 9

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SPOUSE’S FIRST NAME

SPOUSE’S SOCIAL SECURITY NUMBER

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DEPARTMENT USE ONLY

LAST NAME

SUFFIX

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ADDRESS (NUMBER AND STREET or P.O. BOX)

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500 UET Exception

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Residency Status

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

1. FULL- YEAR RESIDENT

2. PART- YEAR RESIDENT

3. NONRESIDENT

Part-Year Residents and Nonresidents must omit Lines 9 thru 14 and use Schedule 3 of Form 500, page 6

Filing Status

5. Enter Filing Status with appropriate letter (See Tax Booklet Page 11)..................................................................................

A. Single

B.Married filing joint

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

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, MI.

Last Name

Social Security Number