I III I (Approved web version) page3) Georgia Form 500 (Rev. 09/02/15)

Transcription

1 I III I Georgia Form 500 (Rev. 09/02/15) (Approved web version) II page3) Fiscal Year Beginn ing Fiscal Year Ending QS-'6SLi-32 o 1. YO UR FIRST NAME MI LAST NAME SUFFIX Special Program Code See 1T-611 Tax Booklet SPOUSE'S FIRST NAME MI SPOUSE'S SOCIAL SECURITY NUMBER DEPARTMENT USE ONLY LAST NAME SUFFIX 2. ADDRESS (NUMBER AND STREET or P.O. BOX) (Use 2nd address line for Apt, Suite or Building Number) CH ECK IF ADDR ESS HAS CHANGED 500 UET Exception Atlached 3. CITY (Please insert a space if the city has multiple names) STATE ZIP CODE (COUNTRY IF FOREIGN) 4. Enter your Residency Status with tile appropriate!lumber... ResJden<.)' Status... ~ FULL- YEAR RESIDENT 2. PART- YEAR RESIDENT TO 3. NONR ESIDENT Part-Year Residents and Nonresidents must omit Lines 9 thru 14 and use Schedule 3 of Form 500, page Enter Filing Status with appropriate letter (See IT Tax Booklet) Filing Status..... ~ 5. A. Single B. Married filing joint C. Married filing separate (Spouse's social security number must be entered above) D. Head of Household or Qualifying Wido~er) 6. Number of exemptions (Check appropriate box(es) and enter total in 6c.) 6a. Yourself 6b. Spouse 6c.

2 Georgia Form 500 I III III a. Number of Dependents (Enter details on Line 7c. and DO NOT include yourself or your spouse) a. 7b. Add Lines 6c and 7a. Enter total b. 7c. Dependents (If you have more than 5 dependents, attach a list of additi onal dependents) Relationship to You Relationship to YOLI Relationship to You Relationship to You Relationship to YOLI

3 Georgia Form If amount on line 8, 9, 10, 13 or 15 is negative, use the minus sign (-). Example -3, Federal adjusted gross income (From Federal For1l1 1040, 1040A or 1040 EZ) ~ 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 enclose a copy of your Federal Form 1040 Pages 1 and s from Schedule 1 (See IT-511 Tax Booklet )... ~ Georgia adjusted gross income (Net total of Line 8 and Line 9) ~ Standard Deduction (Do not use FEDERAL STANDARD DEDUCTION)... ~ 11a. (See IT -511 Tax Booklet) b, Self: 65 or over? Blind? Spouse: 65 or over? Blind? TOlal x 1.300=... ~ 11b. c. Total Standard Deduction (Line 11a + Line 11 I}).....,... ~ 11 c. Use EITHER Line 11c OR Line 12c (Do not w rite on both lines) 12. Total Itemized Deductions used in computing Federal Ta xable Income. If you use itemized deductions, you must enclose Federal Schedule A a. Federal Itemized Deductions (Schedule A-Form 1040) 12a. b. Less adjustments: (See IT-511 Tax Booket)... ~ 12b. c. Georgia Total Itemized Ded uctions , ~ 12c. 13. Subtract either Line 11 c or Line 12c from Line 10; enter ba lance... ~ a. Number on Line 6c. multiply by $2,700 for fi ling statu s A or D ~ OR multiply by $3,700 for filing status B or C 14a. 14b. Number on Line 7a. mu ltiply by $3, ~ 14b. 14c. Add Lines 14a. ancl14b. Enter total '14c, 15. Georgia taxable income (Line 13 less Line 14c or Schedule 3, Line 14)..... ~ Ta x (Use Tax Table in the 1T-51 1 Tax Booklet)..,...,..,.....,... ~ 17. Credits from Form 500, Page 6, Schedule 2, Summary Section, Line 3 (Enter total but not more than the amount on Lin e 16) ~ Balance (Line 16 less Line 17) if zero or less than zero, enter zero... ~ Georgia Income Tax Withheld on Wages and 1099s (Enter Tax Withheld Only and enclose W-2s and/or 1099s) 20. Other Georgia Income Tax Withheld (Must enclose G2-A, G2-FL, G2-LP and/or G2-RP)

4 Georgia Form 500 I III III Estimated tax for and Form IT _... ~ Total prepayment credits (Add Lines 19, 20 and 21 ) ~ If Line 18 exceeds Line 22 enter BALANCE DUE STATE... ~ If Line 22 exceeds Line 18 enter OVERPAYMENT amount... ~ Amount to be credited to 2016 ESTIMATED TAX Georgia Wildlife Conservation Fund (No gift of less than $1.00)..... ~ Georgia Fund for Children and Elderly (No gift of less than $1.00) Georgia Cancer Research Fund (No gift of less than $1.00) Georgia Land Conservation Program (No gift of less than $1.00)... ~ Georgia National Guard Foundation (No gift of less than $1.00) Dog & Cat Sterilization Fund (No gift of less than $1.00)... 3' Saving the Cure Fund (No gift of less than $1.00) ~ Realizing Educational Achievement Can Happen (REACH ) Program... ~ 33. (No gift of less than $1.00) 34. Form 500 UET (Estimated tax penalty)......_..... ~ (If you owe) Add Lines 23, 26 thru 34 MAKE CHECK PAYABLE TO GEORGIA DEPARTMENT OF REVENUE (If you are due a refund) Subtract the sum of Lines 25 thru 34 from Line 24 THIS IS YOUR REFUND ~ a. Direct Deposit (For U.S. Accoullts Only) Type : Checking Savings R outing Numbe r You can help eliminate $1Million of processing costs by choosing Direct DepOS it. If you do not enter Direct Deposit information, a paper check will be issued. (PAYMENT) Account Numbe r PROCESSING CENTER GEORGIA DEPARTMENT OF REVENUE PO BOX ATLANTA. GA 30374'{)399 (REFUND and NO BALANCE DUE) PRO CESSING CENTER GEO RGIA DEPARTMENT OF REVENUE PO BOX ATLANTA, GA30374'{)380 ENCLOSE ALL ITEMS IN RETURN ENVELOPE. DO NOT STAPLE YOUR CHE CK. W-2s. OTHER WITHHOLDING DOCUMENTS. OR TAX RETURN IMie declare under tile penalties of perjury tllat IIwe have exam ined this relurn (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 oth er than the taxpaye r( s), this declaration is based on all information of which the preparer has knowledge. Georgia Public Revenue Code Section stipulates that ta xes shall be paid in lawful money of the United States, free of any expense to the State of Georgia. \ PHONE NUMBER Taxpayer's S ignature (Check box if deceased) DATE Spouse's Signature (Check box if deceased) DATE NAME OF PRE PARER OTHER THAN TAXPAYER Do you want to au thorize DOR to discuss this return with the named preparer. Yes Signature of Preparer I authorize the to electronically notify me at th e below e~m a i l address regarding any updates to my account(s). TAXPAYER'S ADDRESS PREPARER'S FEIN PREPARER 'S SSN/PTIN PHONE NUMBER

5 H 1 H H Georgia Form 500 I III II SCHEDULE 1 ADJUSTMENTS to INCOME BASED on GEORGIA LAW (See IT-511 Tax Booklet) ADDITIONS to INCOME 1. Interest on Non-Georgia Municipal and State Bonds Lump Sum Distributions 3. Federal deduction for income attributable to domestic production activi ties (IRC Section 199) 4. Net operating loss carryover deducted on Federal return Other (Specify) Q E E ere D I T Total Additions (Enter sum of Lines 1-5 here) SUBTRACTION from INCOME 7. Retirement Income Exclusion (See IT-511 Tax Booklet) a. Self: Date of Birth Date of Disability: Type of Disability: 7a. b. Spouse: Date of Birth Date of Disability: Type of Disability: 7b. 8. Social Security Benefits (Taxable pol1ion from Federal return) Path2Coilege 529 Plan Interest on United States Obligations (See IT-511 Tax Booklet) Georgia Net Operating loss caltyover from previous years (See IT-5"11 Tax Booket ) Other s (Specify) Amount Amount Amount Amount Total Total Subtractions (Enter sum of Lines 7-12 here) Net s (Line 6 less Line 13). Enter Net Total here and on Line 9 of Page 3 (+ or - ) of Form

6 Georgia Form 500 Georgia Depal1ment of Revenue I III SCHEDULE 2 CREDIT USAGE AND CARRYOVER See IT -511 Tax Booklet 1. Complete Form INO-CR if applicable and enter the to tal on Line 1 of the summary secti on below. A separate Schedule 2 must be completed for each non IND-CR Credit. Total Line 14 of each Schedule 2 and enter the total on Line 2 of the summary section below. The summary section should only be completed on the first Schedule The ta xpayer must indicate which credits are being used for both the INO-CR ancl non INO-CR credits. 3. If there is a credit eligible for carryover to, please complete the schedules even if the credit is nol used in. 4. See the IT-511 Tax Booklet for a list of non INO-CR credit type codes. 5. See the re levant forms, statutes, a nd regulations to determine how IIle credit is al located to th e owners, to de term ine when carryovers expire, and to see if the credit is limited to a cel1ain percentage of tax. 6. If the credit for a particular non INO-CR credit code originated with more than one person or company, enter separate information on Lines 6 th rougll 11 below. 7. The credit cel1ificate number is issued for credits that are preapproved. If applicable, please enter the credit certificate number where indicated. 8. Before th e Line 15 and INO-CR carryovers are applied to next year, the amount must be reduced by any amounts elected to be applied to withhold ing in (for businesses only) and by any carryovers that have expired. Low Income Credit and Other State(s) Tax Credit have been moved to the INO-CR page 7. Summary of Credits Used 1. Credits used from IND-CR ~ Total credits used from a ll non IND-CR credits (Total of Line 14 for each credit) ~ Total credits used (Enter here and o n Line 17, Page 3 of Form This amolint canllot exceed Line 16, Page 3 of Form 500)... ~ 3. Non IND-CR Credits For the credit generated this year, list the Company Name, ID number, Credit Certificate number, if applicable, and % of credit (purchased credits should also be included). If the credit originated with this taxpayer, enter this taxpayer's name and 10# below and 100% for the percentage Credit Type Code (Enter here and on Page 7)..... ~ Credit remaining from previous years (For businesses only, do not include amounts elected to be applied to w ithholding)... ~ COMPANY NAME CREDIT CERTIFICATE # % OF CREDIT ID NUMBER CREDtT GENERATED IN COMPANY NAME CREDIT CERTIFtCA TE # % OF CREDIT ID NUMBER CREDtT GENERATED IN

7 Georgia Form Georgia Depal1ment of Revenue CREDrTlYPE CODE FROM PAGE 6, LINE SCHEDULE 2 CREDIT USAGE AND CARRYOVER (continued) 8. COMPANY NAME CREDIT CERTIFICATE # % OF CREDIT 10 NUMBER CREDIT GENERATED IN 9. COMPANY NAME CREDIT CERTIFICATE # % OF CREDIT 10 NUMBER CREDIT GENERATED IN 10. COMPANY NAME CREDIT CERTIFICATE # % OF CREDIT 10 NUMBER CREDIT GENERATED IN 11. COMPANY NAME CREDIT CERTIFICATE # % OF CREDIT 10 NUMBER CREDIT GENERATED IN 12. Total available credit for (sum of Li nes 5 through 11 )... ~ Enter the amount of the credit sold (Conservation and Film Tax Credits)..~ Credit Used in ~ Potential carryover to 2016 (Line 12 less Lines 13 and14) ~ 15.

8 Georgia Form 500 (Rev. 09/02/15) (Approved web version) pag(!) Fiscal Year Beginning Fiscal Year Endil1g I '8 2 o 1. YOUR FIRST NAME MI LAST NAME SUFFIX Special Program Code See IT-611 Ta x Booklet SPOUSE'S FIRST NAME MI SPOUSE'S SOCIAL SECURITY NUMBER OEPARTMENT USE ONLY LAST NAME SUFFIX 2. ADDRESS (NUMBER AND STREET or P.O. BOX) (Use 2nd address line for Apt, Suite or Building Number) CHECK IF ADDRESS HAS CHAN GED 50 0 UET Exception Attached 3. CITY (Please insert a space if the city has multiple names) STATE ZIP CODE (COUNTRY IF FOREIGN) 4. Enter your Residency Status with the appropriate number 1. FULL- YEAR RESIDENT 2. PART- YEAR RESIDENT TO Residency Status... ~ NONRESIDENT Part-Year Residents and Nonresidents must omit Lines 9 thru 14 and use Schedule 3 of Form 500, p age Enter Filing Status with appropriate letter (See IT Tax Booklet) Filing Status... ~ 5. A. Single B. Married filing joint C. Married filing separate (Spouse's social security number must be entered above) D. Head of Household or Qualifying Widow(er) 6. Number of exemptions (Check appropriate box(es) and enter total in 6c.) 6a. Yourself 6b. Spouse 6c.

9 Georgia Form 500 Geol gia Department of Revenue a. Number of Dependents (Enter details on Line 7c. and DO NOT include yourself or your spollse) 7b. Add Lines 6c and 7a. Enter tolal.. ~ 7b. 7c. Dependents (If you have more than 5 dependents, attach a list of additi onal dependents) Relationship to You Re lationship to You Relationship to You Relationship to You Relationship to You

10 Georgia Form 500 I III YOURSOC~LSECUruTYNUMBER If amount on line 8, 9, 10, 13 or 15 is negative, use the minus sign (-). Example -3, Federal adjusted gross income (From Federal Form 1 040, 1040A or 1040 EZ)~ 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 enclose a copy of your Federal Form 1040 Pages 1 and s from Schedule 1 (See IT-511 Tax Booklet ) Georgia adjusted gross income (Net total of Line 8 and Line 9) Standard Deduction (Do not use FEDERAL STANDARD DEDUCTION)... 11a. (See IT -511 Tax Booklet) b. Self: 65 QI" over? Blind? Spouse: 65 or over? Blind? Tolal x 1,300=... ~ 11b. c. Total Standard Deduction (Line 11a + Line 11 b).. 11c. Use EITHER Line 11c OR Line 12c (Do not write on both lines) 12. Total Itemized Deductions used in computing Federal Taxable Income. If you use itemized deductions, you must enclose Federal Schedule A a. Federa l Itemized Deductions (Schedule A-Form 1040).. 12a. b. Less adjustments: (See IT-511 Tax Booket)... ~ 12b. c. Georgia Total Itemized Deductions c. 13, Subtract either Line 11 c or Line 12c from Line 10; enter balance... ~ '13. 14a. Number on Line 6c. multiply by $2,700 for filing statu s A or D ~ OR multiply by $3,700 for filin g status B or C 14a. 14b. Number 011 Line 7a. multiply by $3,000.., ~ 1Lib. 14c. Add Lines 14a. and 14b. Enter total.. '1 Lie. 15. Georgia taxable income (Line 13 less Line 14c or Schedule 3, Line 14 ).... ~ Tax (Use Tax Table in the IT-51 1 Tax Booklet) ~ 17. CI'edits from Form 500, Page 6, Schedule 2, Summary Section, Line 3 (Enter total but not more than the amount on Line 16) Balance (Line 16 less Line 17) if zero or less than zero, enter zero... ~ Georgia Income Tax Withheld on Wages and 1099s..... (Enter Tax Withheld On ly and enclose W-2s and/or '1099s) 20. Other Georgia Income Tax Withheld (Must enclose G2-A, G2-FL, G2-LP and/or G2-RP)

11 Georgia Form Estimated ta x for and Form IT _... ~ 2' Total prepayment credits (Add lines 19, 20 and 21 )... ~ If Line 18 exceeds Line 22 enter BALANCE DUE STATE... ~ If Line 22 exceeds Line 18 enter OVERPAYMENT amoun t... ~ Amount to be credited to 2016 ESTIMATED TAX Georgia Wildlife Conservation Fund (No gift of less than $1.00)..... ~ Georgia Fund for Ch ildren and Elderly (No gift of less than $1.00)... ~ Georgia Cancer Research Fund (No gift of less than $1.00) ~ Georgia Land Conservation Program (No gift of less than $1.00)... ~ Georgia National Guard Foundation (No gift of less than $1.00)... ~ Dog & Cat Sterilization Fund (No gift of less than $1.00)... ~ 3' Saving the Cure Funci (No gift of less than $1.00)... ~ Realizing Educational Adlievement Can Happen (REACH) Program... ~ 33. (No gift of less than $1.00) 34. Form 500 UET (Estimated tax penalty)......_... ~ (If you owe) Add Lines 23, 26 thru 34 MAKE CHECK PAYABLE TO GEORGIA DEPARTMENT OF REVENUE... ~ (If you are due a refund) Subtract the sum of Lines 25 thru 34 from Line 24 THIS IS YOUR REFUND... ~ a. Direct Deposit (For U.S. Accou nts Only) Type : Checking Savings Rout ing Number You can help eliminate $1 Million of process ing ( costs by choosing Direct Depos it. If you do not enter Direct Deposit information, a paper check w ill be issued. (PAYMENT) Account Number PROCESSING CENTER GEORGIA DEPARTMENT OF REVENUE I (REFUND a nd NO PO BOX BALANCE DUE) ATLANTA. GA PROCESSING CENTER GEORGIA DEPARTMENT OF REVENUE PO BOX ATLANTA, GA ~~~~~~~~~~~~~~~~ ~ ENCLOSE ALL ITEMS IN RETURN ENVELOPE. DO NOT STAPLE YOUR CHECK. W-2s. OTHER WITHHOLDING DOCUMENTS. OR TAX RETURN IMie declare under tile penalties of perjuly tllat IIwe have examined tilis relurn (including accompanying sclledules and stalements) and to the best of my/our knowledge and be lief, it is true, correct. and complete. If prepared by a person other than the taxpayer(sj, IIl,s declaration is based on all Information of which Ihe preparer has k nowl edg~. Georgia Pu blic Revenue Code Section stipulates that taxes shall be paid in lawlul money of the United States. free of any expense 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 Tl-iAN TAXPAYER Do you want to authorize DOR to discuss this return with the named preparer. Yes Signature of Pre parer I authorize the to electronically notify me at the below address regarding any updates to my account(s}. TAXPAYER'S ADDRESS PREPARER'S FEIN PREPARER'S SSN/PTIN PHONE NUMBER

12 Georgia Form SCHEDULE 1 ADJUSTMENTS to INCOME BASED on GEORGIA LAW (See IT-511 Tax Booklet) ADDITIONS to INCOME 1. Interest on Non-Georgia Municipal and State Bonds ~ Lump Sum Distributions Federal deduction for income attributable to domestic production activities... ~ 3. (IRC Section 199) 4. Net operating loss carryover deducted on Federal return ~ Other (Specify) Q E E ere D I T ~ Total Add itions (Enter sum of Lines 1-5 hel e) ~ 6. SUBTRACTION from INCOME 7. Retirement Income Exclusion (See IT-511 Tax Booklet) a. Self: Date of Birth Date of Disability: Type of Disability: 7a. b. Spouse: Date of Birth Date of Disability: Type of Disability: 7b. 8. Social Security Benefits (Taxable portion from Federal return) Path2Coliege 529 Plan ~ Interest on United States Obligations (See IT-511 Tax Booklet) Georgia Net Operating loss carryover from previous years (See IT-511 Tax Booket ) Other s (Specify) Amount Amount Amoun t Amou nt Total Total Subtractions (Enter sum of Lines 7-12 here) Net s (Line 51ess Line 13). Enter Net Total here and on Line 9 of Page 3 (+ or -) of Form SOD... 1A

13 Georgia Form 500 I III SCHEDULE 2 CREDIT USAGE AND CARRYOVER See IT-511 Tax Booklet 1. Complete Form IND-CR if applicable and enter the total on Line 1 of the summary section below. A separate Schedule 2 must be completed for each non IND-CR Credit. Tota l Line 14 of each Schedule 2 and enter the total on Line 2 of the summary section below. The summary section should only be completed on th e first Schedule The taxpayer must ind ica te which credits are being used for both the IND-CR ami non IND-CR credits. 3. If tl1ere is a credit eligible for carryover to, please complete tile schedules even if the credit is not used In. 4. See the IT-511 Tax Booklet for a list of non IN D-CR cred it type codes. 5. See th e relevant form s, statutes, and regulations to determine 11 0W the cred it is alloca ted 10 the owners, to determine when canyovers expire, and to see if the credit is limited to a certain percentage of tax. 6. If the credit for a palticular non IND-CR credit code originated with more than one person or company, enter separate information on Lines 6 through 11 below. 7. The credit ce l1ificate nu mber is issued for credits that are preapproved. If applicable, please enter the creel it certificate number where indicated. 8. Before the Line 15 and IND-CR ca rryovers are applied to next year, tl1e altlount must I)e reduced by any amounts elected to be applied to withholding In (for businesses only) and by any carryovers 1I1at have expired. Low Income Credit and Other State(s) Tax Credit have been moved to the INO-CR page 7. Summary of Credits Used 1. Credits used from INO-CR. 2. Total credits used from all non INO-CR credits (Total of Line 14 for each credit) Total credits used (Enter here and on Line 17, Page 3 of Form 500. This amount cannot exceed Line 16, Page 3 of FOl"ln 500)..... ~ 3. Non IND-CR Credits For the credit generated this year, list the Company Name, 10 number, Credit Certificate number, if applicable, and % of credit (purchased credits should also be included). If the credit originated with th is taxpayer, enter this taxpayer's name and 10# below and 100% for the percentage Credit Type Code (Enter here and on Page 7).. ~ Credit remaining fro m previous years (For businesses only, do not include amounts elected to be applied to w ithholding) ~ COMPANY NAME CREDIT CERTIFICATE # % OF CREDIT ID NUMBER CREDIT GENERATED IN COMPANY NAME CREDIT CERTIFICATE # % OF CREDIT 10 NUMBER CREDIT GENERATED IN

14 Georgia Form CREDrrlYPE CODE FROM PAGE 6, LINE SCHEDULE 2 CREDIT USAGE AND CARRYOVER (continued) 8. COMPANY NAME CREDIT CERTIFICATE # % OF CREDIT ID NUMBER CREDIT GENERATED IN 9. COMPANY NAME CREDIT CERTIFICATE # % OF CREDIT ID NUMBER CREDIT GENERATED IN 10. COMPANY NAME CREDIT CERTIFICATE # % OF CREDIT ID NUMBER CREDIT GENERATED IN 11. COMPANY NAME CREDIT CERTIFICATE # % OF CREDIT ID NUMBER CREDIT GENERATED IN 12. Total availa ble credit for (slim of Lines 5 tllrollgh 11 )..... ~ Enter the amount of the cred it sold (Conserva tion and Fi lm Tax Credits)... ~ Credit Used in ~ ' Potential carryover to 2016 (Line 12 less Lines "13 and14 ) ~ 15.