Preparer Conservation Program
Resume:
Georgia Form *** (Rev. **/**/**)
Individual Income Tax Return
Georgia Department of Revenue
**** (Approved software version)
Page 1
PAGES (1-5) ARE REQUIRED FOR PROCESSING
2. PART- YEAR RESIDENT TO 3. NONRESIDENT
CITY (Please insert a space if the city has multiple names) STATE ZIP CODE D. Head of Household or Qualifying Widow(er)
SPOUSE’S FIRST NAME MI
6a. Yourself 6b. Spouse 6c.
5. Enter Filing Status with appropriate letter (See I T -511 Tax Booklet) 5. rsion) Fiscal Year
Ending
6. Number of exemptions (Check appropriate box(es) and enter total in 6c.) Filing Status
A. Single B.Married filing joint C.Married filing separate(Spouse’s social security number must be entered above) Omit Lines 9 thru 14 and use Form 500 Schedule 3 if you are a part-year or nonresident filer.
(Use 2nd address line for Apt, Suite or Building Number) LAST NAME
SUFFIX
LAST NAME SUFFIX
ADDRESS (NUMBER AND STREET or P.O. BOX) CHECK IF ADDRESS HAS CHANGED SPOUSE’S SOCIAL SECURITY NUMBER
(COUNTRY IF FOREIGN)
DEPARTMENT USE ONLY
YOUR SOCIAL SECURITY NUMBER
1.
2.
3.
1. FULL- YEAR RESIDENT
4. Enter your Residency Status with the appropriate number Residency Status
4.
Fiscal Year
Beginning
YOUR FIRST NAME MI
7a. Number of Dependents (Enter details on Line 7b., and DO NOT include yourself or your spouse) 7a.
(For Name Change See IT-511 Tax Booklet)
STATE
ISSUED
YOUR DRIVER’S
LICENSE/STATE ID
STACY ***-**-****
HALL
3003 TRIBUTARY WAY
Decatur GA 30034
1
D
1
064180417
GA
8
1
Pag e 2
Georgia Individual Form500 Income Tax Return
Georgia Department of Revenue
2021
YOUR SOCIAL SECURITY NUMBER
7b. Dependents (If you have more than 4 dependents, attach a list of additional dependents) First Name, MI. Last Name
Social Security Number Relationship to You
PAGES (1-5) ARE REQUIRED FOR PROCESSING
9. Adjustments from Form 500 Schedule 1 (See IT-511 Tax Booklet) 10. Georgia adjusted gross income (Net total of Line 8 and Line 9) 8. Federal adjusted gross income (From Federal Form 1040) If amount on line 8, 9, 10, 13 or 15 is negative, use the minus sign . Example -3456. 8.
(Do not use FEDERAL TAXABLE INCOME) If the amount on Line 8 is $40,000 or more, or your gross income is less than your W-2s you must include a copy of your Federal Form 1040 Pages 1, 2, and Schedule 1. 10.
9.
INCOME COMPUTATIONS
First Name, MI. Last Name
Social Security Number Relationship to You
First Name, MI. Last Name
Social Security Number Relationship to You
Social Security Number Relationship to You
11. Standard Deduction (Do not use FEDERAL STANDARD DEDUCTION)
(See IT-511 Tax Booklet)
c. Total Standard Deduction (Line 11a + Line 11b) b. Self: 65 or over? Blind?
Spouse: 65 or over? Blind?
Total x 1,300
Use EITHER Line 11c OR Line 12c (Do not write on both lines) 11c.
11b.
11a.
12. Total Itemized Deductions used in computing Federal Taxable Income. If you use itemized deductions, you must include Federal Schedule A. a. Federal Itemized Deductions (Schedule A- Form 1040) b. Less adjustments: (See IT-511 Tax Booklet) 12a.
12c.
12b.
c. Georgia Total Itemized Deductions 13. Subtract either Line 11c or Line 12c from Line 10; enter balance 13. First Name, MI. Last Name
LEAH TOWNSEND
***-**-**** DAUGHTER
21,115
0
21,115
***-**-****
4,600
0
0
0
0
16,515
4,600
0
0
Georgia Individual Form500 Income Tax Return
Georgia Department of Revenue
2021 YOUR SOCIAL SECURITY NUMBER
Pag e 3
(INCOME STATEMENT A) (INCOME STATEMENT B)
1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE:
(INCOME STATEMENT C)
W -2 G2-A G2-LP W -2 G2-A G2-LP W -2 G2-A G2-LP
1099 G2-FL G2-RP 1099 G2-FL G2-RP 1099 G2-FL G2-RP 2. EMPLOYER/PAYER FEDERAL
ID NUMBER (FEIN) SSN
2. EMPLOYER/PAYER FEDERAL
ID NUMBER (FEIN) SSN
2. EMPLOYER/PAYER FEDERAL
ID NUMBER (FEIN) SSN
3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID 4. GA WAGES / INCOME 4. GA WAGES / INCOME 4. GA WAGES / INCOME 5. GA TAX WITHHELD 5. GA TAX WITHHELD 5. GA TAX WITHHELD PLEASE COMPLETE INCOME STATEMENT DETAILS ON PAGE 4. INCOME STATEMENT DETAILS Only enter income on which Georgia tax was withheld. Enter income from W-2s, 1099s, and G2-As on Line 4 GA Wages/Income. For other income statements complete Line 4 using the income reported from Form G2-RP Line 12 or 13; Form G2-LP Line 11, or for Form G2-FL enter zero.
PAGES (1-5) ARE REQUIRED FOR PROCESSING
14a. Enter the number from Line 6c. Multiply by $2,700 for filing status A or D 14a. 14b. Enter the number from Line 7a.
or multiply by $3,700 for filing status B or C
Multiply by $3,000 14b. 14c. Add Lines 14a. and 14b. Enter total 14c. 16. 16.
17. 17a. 17b.
Low Income Credit 17c.
18.
19.
Other State(s) Tax Credit (Include a copy of the other state(s) return) 18. C redits used from IND-CR Summary Worksheet 19. 20. Total Credits Used from Schedule 2 Georgia Tax Credits (must be filed electronically)
20.
21. 21.
22. Balance (Line 16 less Line 21) if zero or less than zero, enter zero 22. Total Credits Used (sum of Lines 17-20) cannot ex ceed Line 16 15a. Income before GA NOL (Line 13 less Line 14c or Schedule 3, Line 14) 15a. 15b.
15b. Georgia NOL utilized (Cannot exceed Line 15a or the amount after applying the 80% limitation, see IT-511 Tax Booklet for more information) 15c. Georgia Taxable Income (Line 15a less Line 15b) 15c. Tax (Use Tax Table or Tax Rate Schedule in the IT-511 Tax Booklet) ***-**-****
2,700
5,700
1
1
386
3,000
10,815
386.862
0
0
0
0
2 0
Advanced Tax Solutions, LLC 03-193*-***-**** GA 004 T1 21 0
10,815
8
8
562118337
3246298FO
16,241
734
Georgia Individual Form500 Income Tax Return
2021 Georgia Department of Revenue YOUR SOCIAL SECURITY NUMBER PAGES (1-5) ARE REQUIRED FOR PROCESSING
Page 4
2. EMPLOYER/PAYER FEDERAL
ID NUMBER (FEIN) SSN
2. EMPLOYER/PAYER FEDERAL
ID NUMBER (FEIN) SSN
3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID
(INCOME STATEMENT E)
2. EMPLOYER/PAYER FEDERAL
ID NUMBER (FEIN) SSN
1. WITHHOLDING TYPE:
3. EMPLOYER/PAYER STATE WITHHOLDING ID
4. GA WAGES / INCOME
1. WITHHOLDING TYPE:
5. GA TAX WITHHELD 5. GA TAX WITHHELD
4. GA WAGES / INCOME
1. WITHHOLDING TYPE:
5. GA TAX WITHHELD
4. GA WAGES / INCOME
(INCOME STATEMENT D) (INCOME STATEMENT F)
W- 2
1099
G2-A
G2-FL
G2-LP
G2-RP
W- 2
1099
G2-A
G2-FL
G2-LP
G2-RP
W- 2
1099
G2-A
G2-FL
G2-LP
G2-RP
25. Estimated Tax paid for 2021 and Form IT-560 23.
24. Other Georgia Income Tax Withheld 24.
(Enter Tax Withheld Only and include W-2s and/or 1099s) 23.
(Must include G2-A, G2-FL, G2-LP and/or G2-RP)
Georgia Income Tax Withheld on Wages and 1099s 28. If Line 22 exceeds Line 27, subtract Line 27 from Line 22 and enter balance due 28. 26.
overpayment 27.
29. If Line 27 exceeds Line 22, subtract Line 22 from Line 27 and enter 29.
30. Amount to be credited to 2022 ESTIMATED TAX 31.
32.
Georgia Wildlife Conservation Fund (No gift of less than $1.00) Georgia Fund for Children and Elderly (No gift of less than $1.00) 33. Georgia Cancer Research Fund (No gift of less than $1.00) 34. Georgia Land Conservation Program (No gift of less than $1.00) 35.
36 .
Georgia National Guard Foundation (No gift of less than $1.00) Dog & Cat Sterilization Fund (No gift of less than $1.00) Saving the Cure Fund (No gift of less than $1.00)
(No gift of less than $1.00)
Realizing Educational Achievement Can Happen (REACH) Program 38. 37. 37.
31.
30.
32.
33.
34.
35.
36.
38.
25.
26. Schedule 2B Refundable Tax Credits
(Cannot be claimed unless filed electronically)
27. Total prepayment credits (Add Lines 23, 24, 25 and 26) ***-**-****
947
0
561
947
0
0
0
8
061705127
8
2240711ZV
4,874
213
Georgia Individual Form500 Income Tax Return
Georgia Department of Revenue
2021
YOUR SOCIAL SECURITY NUMBER
Pag e 5
PAGES (1-5) ARE REQUIRED FOR PROCESSING
42.
40. Form 500 UET (Estimated tax penalty) 500 UET exception attached 40. Routing
41. (If you owe) Add Lines 28, 31 thru 40
THIS IS YOUR REFUND Number
Account
Type: Checking
Savings
Number
MAKE CHECK PAYABLE TO GEORGIA DEPARTMENT OF REVENUE. . 41.
Amount Due Mail To:
GEORGIA DEPARTMENT OF REVENUE
PROCESSING CENTER, PO BOX 740399
ATLANTA, GA 30374-0399
42. (If you are due a refund) Subtract the sum of Lines 30 thru 40 from Line 29 If you do not enter Direct Deposit information or if you are a first time filer you will be issued a paper check. 42a. Direct Deposit (U.S. Accounts Only)
Refund Due Mail To:
GEORGIA DEPARTMENT OF REVENUE
PROCESSING CENTER, PO BOX 740380
ATLANTA, GA 30374-0380
INCLUDE ALL ITEMS IN ENVELOPE, DO NOT STAPL E YOUR CHECK, W-2s, OTHER WITHHOLDING DOCUMENTS, OR TAX RETURN. I/We declare under the penalties of perjury that I/we have examined this return (including accompanying schedules and statements) and to the best of my/our knowledge and belief, it is true, correct, and complete. If prepared by a person other than the taxpayer(s), this declaration is based on all information of which the preparer has knowledge. 39. Public Safety Memorial Grant (No gift of less than $1.00) 39. Taxpayer’s Signature (Check box if deceased) Spouse’s Signature (Check box if deceased) By providing my e-mail address I am authorizing the Georgia Department of Revenue to electronically notify me at the below e-ma il address regarding any updates to my account(s).
Taxpayer’s E-mail Address
Preparer’s Firm Name
Signature of Preparer
Name of Preparer Other Than Taxpayer
I authorize DOR to discuss this return
with the named preparer.
Taxpayer’s Phone Number Spouse’s Signature Date
Preparer’s Phone Number
Preparer’s FEIN
Preparer’s SSN/PTIN/SIDN
Taxpayer’s Date of Death Spouse’s Date of Death
Taxpayer’s Signature Date
***-**-****
0
0
NAJJA HATCHETT
NGH INCOME TAX SERVICES
26-2038929
561
P01355287
404- 919-644
061092387
219915565
03/07/2022
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