Georgia Form 500 -Individual Income Tax Return

Page 3 Form 500 1999 Schedule

Social Security Number:

Name:

SCHEDULE 1 ADJUSTMENTS TO INCOME BASED ON GEORGIA LAW (see page 7 of instructions)

ADDITIONS TO INCOME

1. Interest on Non-Georgia Municipal and State Bonds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. Lump Sum Distributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Total Additions (enter sum of lines 1-3 here) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SUBTRACTIONS FROM INCOME

5. Retirement Income Exclusion

Type of Disability:

(See Retirement income exclusion worksheet page 13.)

A. Self: Date of Birth

Date of Disability:

Type of Disability:

B. Spouse: Date of Birth

Date of Disability:

6. Social Security Benefits (Taxable Portion) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7. Railroad Retirement Benefits (Taxable Portion) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8. Interest on United States Obligations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(See page 7 of instructions.)

9. Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10. Total Subtractions (enter sum on Lines 5-9 here). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11. Net Adjustments (Line 4 less Line 10, enter net total here and on Line 9 of Page 1) (+ or -) .

SCHEDULE 2 CREDITS FOR LINE 17 PAGE 2

1. Other State Credit (see worksheet, page 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. Low Emission Vehicle Credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Rural Physicians Credit (complete Form IND-CR. See page 18). . . . . . . . . . . . . . . . . . . . . . . . . . . . .

County of Residence____________County of Practice____________Type of Practice________________

4. Disabled Person Home Purchase or Retrofit Credit (complete Form IND-CR. See page 18). . . . . . .

5. Qualified Caregiving Expense Credit (complete Form IND-CR. See page 18). . . . . . . . . . . . . . . . . . .

Pass Through Credits from Ownership of Sole Proprietor, S Corp., LLC, LLP or Partnership Interest

6. Employer’s Credit for Basic Skills Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .