Form It-550 - Claim For Refund Of Georgia Income Tax Erroneously Or Illegally Collected

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IT-550 (Rev. 2/02)
CLAIM FOR REFUND OF GEORGIA INCOME TAX
STATE OF GEORGIA
ERRONEOUSLY OR ILLEGALLY COLLECTED
DEPARTMENT OF REVENUE
INCOME TAX DIVISION
Name
IMPORTANT
SEE INSTRUCTIONS ON
Street and Number
BACK PAGE FOR USES
OF THIS FORM AND
City or Town
County
State
Zip Code
FOR MAILING
ADDRESSES
Federal Employer I.D. No.
GA. Withholding Tax Account No.
Taxpayer’s S.S. Number
Spouse’s S.S. Number
Tax Type:
Withholding
Corporate
Individual
1. Taxable year or period for which taxes were paid:
Calendar year or period___________________________ or fiscal year ending_____________________ , ___________
2. Amount of tax paid
$_______________
3. Amount of tax due
$_______________
4. Amount of refund claimed
$_______________
Claimant believes that this claim should be allowed for the following reasons:
(Attach separate pages if additional space is needed)
I (we) declare under the penalties of perjury that this claim (including any accompanying schedules and statements) has been
examined by me (us) and to the best of my (our) knowledge and belief is true and correct.
Date__________________ , ___________
Signed: __________________________________________
(Claim must be signed by both husband and wife if
__________________________________________
a joint return was filed. Corporate officer should state their title. )
__________________________________________________________________________________________________________
This section is for official use only. I recommend that action on this claim be taken as indicated in the following schedule.
Amount Claimed
$____________________
Amount Rejected
$____________________
Amount Allowed
$____________________
Interest From_____________To_____________
$____________________
Total
$____________________
__________________________________________
(Examination Agent)
Approved by
__________________________________________
(Approving Agent)
Based on the facts as stated in this claim and on the certificate of the Examining and Approving Agents, as above,
it is directed that the refund be issued or denied.
DEPARTMENT OF REVENUE, INCOME TAX DIVISION
Dated___________________________ ,________
By_____________________________________________

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