Form 500 - Georgia Individual Income Tax Return - 2014 Page 3

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500
Georgia Form
Individual Income Tax Return
Georgia Department of Revenue
2014
YOUR SOCIAL SECURITY NUMBER
.
00
21. Estimated tax for 2014 and Form IT-560
.....................................................
21.
.
00
22.
22.
Total prepayment credits (Add Lines 19, 20 and 21)...................................
.
00
23.
If Line 18 exceeds Line 22 enter BALANCE DUE STATE
23.
...............................
.
00
24.
If Line 22 exceeds Line 18 enter OVERPAYMENT amount
...........................
24.
.
00
25.
Amount to be credited to 2015 ESTIMATED TAX ....................................
25.
.
00
26.
26.
Georgia Wildlife Conservation Fund (No gift of less than $1.00)..................
.
00
27.
27.
Georgia Fund for Children and Elderly (No gift of less than $1.00)............
.
00
28.
Georgia Cancer Research Fund (No gift of less than $1.00) ......................
28.
.
00
29.
Georgia Land Conservation Program (No gift of less than $1.00)...............
29.
.
00
30.
Georgia National Guard Foundation (No gift of less than $1.00) .................
30.
.
00
31.
Dog & Cat Sterilization Fund (No gift of less than $1.00) ...........................
31.
.
00
32.
Saving the Cure Fund (No gift of less than $1.00)......................................
32.
,
.
00
33. FOR DEPARTMENT USE ONLY
33.
.
00
34.
Form 500 UET (Estimated tax penalty).........................................................
34.
.
(If you owe) Add Lines 23, 26 thru 34
35.
00
............
MAKE CHECK PAYABLE TO GEORGIA DEPARTMENT OF REVENUE
35.
.
36.
Subtract the sum of Lines 25 thru 34 from Line 24
(If you are due a refund)
00
.............................................................
THIS IS YOUR REFUND
36.
Select only one option - See booklet page 13.
Routing
36a. Direct Deposit
Type: Checking
Savings
(For U.S. Accounts Only)
Number
Debit Card
36b.
Account
Number
You can help eliminate $1Million of process ing
PROCESSING CENTER
PROCESSING CENTER
Blue Label:
Green Label:
GEORGIA DEPARTMENT OF REVENUE
GEORGIA DEPARTMENT OF REVENUE
costs by choosing Direct Deposit or Debit Card.
(REFUND and NO
(PAYMENT )
PO BOX 740399
PO BOX 740380
If you do not select Direct Deposit or Debit Card, a
BALANCE DUE)
ATLANTA, GA 30374-0399
ATLANTA, GA 30374-0380
paper check will be issued.
ENCLOSE ALL ITEMS IN RETURN ENVELOPE. DO NOT STAPLE YOUR CHECK, W-2s, OTHER WITHHOLDING DOCUMENTS, OR TAX RETURN
Under penalty of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief it is
true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. Georgia Public Code Section
48-2-31 requires that taxes shall be paid in lawful money of the United States, free of any expenses to the State of Georgia.
PHONE NUMBER
Taxpayer’s Signature
(Check box if deceased)
DATE
Spouse’s Signature
(Check box if deceased)
DATE
NAME OF PREPARER OTHER THAN TAXPAYER
Do you want to authorize DOR to discuss this return with the
named preparer.
Yes
PREPARER’S FEIN
Signature of Preparer
PREPARER’S SSN/PTIN
I authorize the Georgia Department of Revenue to
electronically notify me at the below e-mail address
regarding any updates to my account(s).
PHONE NUMBER
TAXPAYER’S EMAIL
ADDRESS

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