Form Ga-8453 - Georgia Individual Income Tax Declaration For Electronic Filing Summary Of Agreement Between Taxpayer And Ero Or Paid Preparer - 2015
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1PRINT
CLEAR
ERO MUST RETAIN THIS FORM
DO NOT SUBMIT THIS FORM TO
GEORGIA DEPARTMENT OF REVENUE
UNLESS REQUESTED TO DO SO.
GA-8453
IRS DCN OR SUBMISSION ID
2015
GEORGIA INDIVIDUAL INCOME TAX DECLARATION FOR ELECTRONIC FILING
SUMMARY OF AGREEMENT BETWEEN TAXPAYER AND ERO OR PAID PREPARER
First Name and Initial
Last Name
Social Security Number
If Joint Return, Spouse’s First Name and Initial
Spouse’s Last Name
Spouse’s Social Security Number
Home address (number and street)
Apt Number
Daytime Telephone Number
City, Town or Post Office, State and Zip Code
P
I
TAX RETURN INFORMATION
ART
1. Federal Adjusted Gross Income (Form 500, Line 8; Form 500EZ, Line 1) .......................................... 1.
2. Georgia Taxable Income (Form 500, Line 15; Form 500EZ, Line 3) .................................................... 2.
3. Net Georgia Tax (Form 500, Line 18; Form 500EZ, Line 6) ................................................................. 3.
4. Refund (Form 500, Line 36; Form 500EZ Line 20) ............................................................................... 4.
5. Balance Due (Form 500, Line 35; Form 500EZ, Line 19) ..................................................................... 5.
P
II
DECLARATION OF TAXPAYER(S)
ART
Under penalties of perjury, I declare that the information I have provided to my Electronic Return Originator (ERO) and/or Online Service
Provider and/or Transmitter and the amounts shown in Part I agree with the amounts shown on the corresponding lines of the electronic
portion of my 2015 Georgia Income Tax Return. I declare that I have examined my tax return, including accompanying schedules and
statements, and to the best of my knowledge and belief, my return is true, correct and complete. I consent that the electronic portion of my
return may be sent by my ERO/Online Service Provider/Transmitter.
S
IGN
H
TAXPAYER’S SIGNATURE
Date
SPOUSE’S SIGNATURE (if joint return, both must sign)
Date
ERE
EMAIL ADDRESS
PRINT NAME
P
III
DECLARATION OF ELECTRONIC RETURNS ORIGINATOR AND PAID PREPARER
ART
I DECLARE THAT I HAVE REVIEWED THE ABOVE TAXPAYER’S RETURN AND THAT THE ENTRIES ON THE GA-8453 ARE COMPLETE
AND CORRECT TO THE BEST OF MY KNOWLEDGE.
ERO’s Signature _____________________________________________________________
Date ______________________
ERO’s
Firm’s Name
_______________________________________________________________
Check if also paid preparer
Use
Address
_______________________________________________________________
FEIN/PTIN
Only
_______________________________________________________________
SSN/TIN
IF PREPARED BYANY PERSON OTHER THAN THE TAXPAYER, THIS DECLARATION IS BASED ON ALL INFORMATION OF WHICH
THE TAXPAYER HAS ANY KNOWLEDGE.
Paid Preparer’s Signature _____________________________________________________
Date ______________________
Paid
Firm’s Name
_______________________________________________________________
FID/TIN
Preparer’s
Address
_______________________________________________________________
SSN/TIN
Use Only
_______________________________________________________________
GA-8453 (REV 9/15)
KEEP A COPY WITH YOUR RECORDS
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