Form Tsd-1 - Protest Of Proposed Assessment Or Refund Denial - Georgia Department Of Revenue

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TSD-1
Page 1
(Rev. 12/11)
Form
Georgia Department of Revenue
Protest of Proposed Assessment or Refund Denial
ECTION 2
Choose protest t pe
SECTION 1
Choose Protest Type
Protest of Proposed Assessment
Protest of Refund Denial
ECTION 3
T
SECTION 2
Tax Information
Enter Letter ID number listed on the Notice of Proposed Assessment or Refund Denial (if available): L
Check tax type and enter the related tax identification number and tax periods at issue:
FEIN:
SSN:
-
Individual Income Tax
Corporate Income Tax
-
-
STN:
IFTA: GA
Sales and Use Tax
IFTA Fuel Tax
TAX ID:
WTN:
-
Other
Withholding Tax
Check if you are being assessed as a
responsible person for sales or withholding taxes or as a
successor to a business.
Tax periods listed on Notice of Proposed Assessment or Refund Denial:
ECTION 1
SECTION 3
Taxpayer Contact Information
axpayer
ntact Information
Taxpayer’s First Name
Middle Initial
Last Name
Social Security Number
Middle Initial
Last Name
Social Security Number
Spouse’s First Name (if joint liability)
Business Name (use if business is being assessed)
Employer Identification Number
Taxpayer’s Address
Daytime Telephone Number
City
State
ZIP
Mailing Address
City
State
ZIP
SECTION 4
Representative Information
ECTION 4
Representative Information
Complete this section only if you are being represented by an attorney, accountant, or other third party. A Power of Attorney (Form RD-
1061) authorizing the representative to act for the taxpayer must be included with the protest form.
Name
Telephone Number
Fax Number
Mailing Address
City
State
ZIP
SECTION 5
Conference Request
ECTION 4
Representative Information
Check either box:
Taxpayer requests a conference with a Department representative regarding the Notice of Proposed Assessment or Refund Denial.
Taxpayer does not request a conference. The protest will be determined based upon the contents of this form, any attached
document’s and the Department’s records.

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