Georgia Form 500 - Indvidual Income Tax Return/georgia Form Ind-Cr - State Of Georgia Individual Credit Form - 2015 Page 4

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Page

500

Georgia Form

Individual Income Tax Return

Georgia Department of Revenue

2015

YOUR SOCIAL SECURITY NUMBER

21. Estimated tax for 2015 and Form IT-560

.....................................................

21.

22.

Total prepayment credits (Add Lines 19, 20 and 21)...................................

23.

If Line 18 exceeds Line 22 enter BALANCE DUE STATE

23.

...............................

24.

If Line 22 exceeds Line 18 enter OVERPAYMENT amount

...........................

24.

25.

Amount to be credited to 2016 ESTIMATED TAX ....................................

25.

26.

Georgia Wildlife Conservation Fund (No gift of less than $1.00)..................

27.

Georgia Fund for Children and Elderly (No gift of less than $1.00)............

28.

Georgia Cancer Research Fund (No gift of less than $1.00) ......................

28.

29.

Georgia Land Conservation Program (No gift of less than $1.00)...............

29.

30.

Georgia National Guard Foundation (No gift of less than $1.00) .................

30.

31.

Dog & Cat Sterilization Fund (No gift of less than $1.00) ...........................

31.

32.

Saving the Cure Fund (No gift of less than $1.00).....................................

32.

33.

Realizing Educational Achievement Can Happen (REACH) Program .................

33.

(No gift of less than $1.00)

Form 500 UET (Estimated tax penalty).........................................................

34.

(If you owe) Add Lines 23, 26 thru 34

35.

............

MAKE CHECK PAYABLE TO GEORGIA DEPARTMENT OF REVENUE

35.

36.

Subtract the sum of Lines 25 thru 34 from Line 24

(If you are due a refund)

.............................................................

THIS IS YOUR REFUND

36.

Routing

36a. Direct Deposit

Type: Checking

Savings

(For U.S. Accounts Only)

Number

Account

Number

You can help eliminate $1Million of process ing

PROCESSING CENTER

(REFUND and NO

(PAYMENT)

GEORGIA DEPARTMENT OF REVENUE

costs by choosing Direct Deposit. If you do not

BALANCE DUE)

PO BOX 740399

PO BOX 740380

enter Direct Deposit information, a paper check

ATLANTA, GA 30374-0399

ATLANTA, GA 30374-0380

will be issued.

ENCLOSE ALL ITEMS IN RETURN ENVELOPE. DO NOT STAPLE YOUR CHECK, W-2s, OTHER WITHHOLDING DOCUMENTS, OR TAX RETURN

I/We declare under the penalties of perjury that I/we have examined this return (including accompanying schedules and statements) and to the best of my/our knowledge

and belief, it is true, correct, and complete. If prepared by a person other than the taxpayer(s), this declaration is based on all information of which the preparer has knowledge.

Georgia Public Revenue Code Section 48-2-31 stipulates that taxes shall be paid in lawful money of the United States, free of any expense to the State of Georgia.

PHONE NUMBER

Taxpayer’s Signature

(Check box if deceased)

DATE

Spouse’s Signature

(Check box if deceased)

DATE

NAME OF PREPARER OTHER THAN TAXPAYER

Do you want to authorize DOR to discuss this return with the

named preparer.

Yes

PREPARER’S FEIN