Form Ia-81 - Replacement Check Request Form
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Form IA-81
Replacement Check Request Form
GENERAL INSTRUCTIONS
• DO Use this form to replace a refund check that has been mailed but never received.
• DO Use this form to request a stop payment on a check that has been lost, stolen or destroyed.
• DO Use this form if you have a refund check that has expired and has not been cashed for more than 180 days after
issuance.
• DON’T Request a replacement check if it has been less than 15 business days since the check was mailed.
• PLEASE Allow 10-15 business days processing time for your completed form.
REFUND TAX YEAR: _____________
REFUND AMOUNT: $_______________
Check Tax Type:
Motor Fuel
IFTA
Corporate
Individual
Sales and use tax
Withholding
TAXPAYER INFORMATION (E-mail: ____________________________________________)
Primary Taxpayer Name or Name of Business:
Spouse Name (if applicable):
SSN
SSN (spouse, if applicable)
-
-
-
-
State Tax Identification Number (STI)
Check Number (if known)
Mailing Address on Return:
City
State
Zip
Current Mailing Address: (if different from above)
City
State
Zip
Daytime Telephone Number
Fax Number
Name of Contact Person (if applicable)
Reasons for request (choose one):
Check Never Received
Direct Deposit Never Received
Lost
Stolen
Expired
Other (Please Explain :__________________________________)
Destroyed
Note: A “STOP PAYMENT” will be issued on the original refund check upon receipt of this form. If you receive/find your
original check after submitting this form, DO NOT CASH THE ORIGINAL CHECK. You must return the check to the Department.
DECLARATION:
I hereby declare, under penalties of perjury, that I have examined this request and, to the best of my knowledge and belief, it is true, correct
and complete. If you are being represented by an attorney, accountant, or other third party, a properly executed Power of Attorney (Form
RD-1061) authorizing the representative to act for the taxpayer must be included with this form.
Taxpayer’s Signature and Date
Spouse’s Signature and Date (if applicable)
Representative’s Name
Title (if applicable)
Representative’s Signature
Date
HOW TO SUBMIT YOUR FORM:
You may submit your completed request to the Department as follows:
Mail to: Georgia Department of Revenue, 1800 Century Center Blvd NE, Suite 3104, Atlanta, GA 30345-3212
Fax: 404-417-4391
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