Form 500x - Amended Individual Income Tax Return - 2014 Page 2
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500X
Georgia Form
(Rev. 10/14)
Amended Individual Income Tax Return
Georgia Department of Revenue
This return is for calendar year
Please print your numbers like this in black or blue ink:
Please print your numbers like this in black or blue ink:
2014
Amended due to IRS Audit
ver ion)
Fiscal Year
Fiscal Year
Beginning
Ending
YOUR FIRST NAME
MI
YOUR SOCIAL SECURITY NUMBER
1.
LAST NAME
SUFFIX
Special Program Code
See Tax Booklet on Page 9
SPOUSE’S FIRST NAME
MI
SPOUSE’S SOCIAL SECURITY NUMBER
DEPARTMENT USE ONLY
LAST NAME
SUFFIX
CHECK IF ADDRESS HAS CHANGED
ADDRESS (NUMBER AND STREET or P.O. BOX)
(Use 2nd address line for Apt, Suite or Building Number)
2.
500 UET Exception
Attached
CITY (Please insert a space if the city has multiple names)
STATE
ZIP CODE
3.
(COUNTRY IF FOREIGN)
Residency Status
4. Enter your Residency Status with the appropriate number.................................................................................................................
4.
1. FULL- YEAR RESIDENT
2. PART- YEAR RESIDENT
TO
3. NONRESIDENT
Part-Year Residents and Nonresidents must omit Lines 9 thru 14 and use Schedule 3 of Form 500X.
Filing Status
. 5
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5.
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.
7.
Dependents (If you have more than 3 dependents, attach a list of additional dependents)
First Name, MI.
Last Name
Social Security Number
Relationship to You
First Name, MI.
Last Name
Social Security Number
Relationship to You
First Name, MI.
Last Name
Social Security Number
Relationship to You
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