Post Office Service Provider

ERO MUST RETAIN THIS FORM.

DO NOT SUBMIT THIS FORM TO

GEORGIA DEPARTMENT OF REVENUE

UNLESS REQUESTED TO DO SO.

IRSDCN OR SUBMISSION ID GA-8453

GEORGI A INDIVIDU AL INC OME TA X DECLARATI ON FOR ELECTRONIC FILING SUMMARY OF AGREEMENT BETWEEN TAXPAYER AND ERO OR PAID PREPARER

$PHQGHG 5HWXUQ

First Name and Initial Last Name Social Security Number I f J oint Retur n, Spouse’ s Firs t N ame and Initial Spouse’s Last Name Spouse’s Social Security Number Home Address (number and street) Apt Number Daytime Telephone Number City, Town or Post Office State Zip Code

PART I TAX RETURN INFORMATION

, Line 8; Form 500EZ, Line 1) 1.

, Line 15c; Form 500EZ, Line 3) 2.

, Line 22; Form 500EZ, Line 6) 3. 4.. Balance Due (Form 500, Line 4 ; Form 500X, Line 37; Form 500EZ, Line 2 ) 4. 5.. Refund (Form 500, Line 4 ; Form 500X, Line 38; Form 500EZ, Line 2 ) 5. PART II DECLARATION OF TAXPAYER(S)

SIGN

HERE TAXPAYER’SSIGNATURE Date SPOUSE’S SIGNATURE (if joint return, both must sig n) Date PRINT NAME EMAIL ADDRESS

PART III DECLARATION OF ELECTRONIC RETURNS ORIGINATOR AND PAID PREPARER I DECLARETHATIHAVEREVIEWEDTHEABOVETAXPAYER’SRETURNANDTHATTHEENTRIESONTHEGA-8453ARECOMPLETE AND CORRECTTOTHEBESTOFMYKNOWLEDGE.

ERO’s Signature Date Firm’sName Check also if paid preparer Address FEIN/PTIN ERO’s

Use

Only

City, State, & Zip Code SSN/TIN IF PREPARED BYANY PERSON OTHER THAN THE TAXPAYER, THIS DECLARATION IS BASED ONALL INFORMATION OFWHICH THE PREPARER HASANYKNOWLEDGE.

Paid Preparer’s Signature Date Paid

Preparer’s

Firm’s Name Address City, State, & Zip Code FID/TIN

Use Only SSN/TIN

GA-8453 (REV ) KEEP A COPY WITH YOUR RECORDS 1. Federal Adjusted Gross Income (Form 500

2. Georgia Taxable Income (Form 500

3. Net Georgia Tax (Form 500

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202

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 202 Georgia Income Tax Return. I declare that I have examined my tax return, including accompanying schedules and 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. VANESSA W LESTER ***-**-****

2252 VERNA DRIVE

DECATUR GA 30034

43687

35587

1874

151

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