Form Ga-8453 - Georgia Individual Income Tax Declaration For Electronic Filing Summary Of Agreement Between Taxpayer And Ero Or Paid Preparer - 2012

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PRINT
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
201 2
0 0
1 3
GEORGIA INDIVIDUAL INCOME TAX DECLARATION FOR ELECTRONIC FILING
SUMMARY OF AGREEMENT BETWEEN TAXPAYER AND ERO OR PAID PREPARER
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If Joint Return, Spouse’s First Name and Initial
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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 4) ................................................................. 3.
4. Refund (Form 500, Line 36; Form 500EZ Line 20) ............................................................................... 4.
5. Balance Due (Form 500, Line 35; Form 500EZ, Line 19) ..................................................................... 5.
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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 2012 Georgia Income Tax Return. I declare that I have examined my tax return, including accompanying schedules a nd
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 5/12)
KEEP A COPY WITH YOUR RECORDS

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