IT 511

Rev. 02.09.22 Brian Kemp Robyn A. Crittenden Governor Revenue Commissioner Georgia Department of Revenue 2021 Individual Income Tax 500 and 500EZ Forms and General Instructions WHAT'S INSIDE? ELECTRONIC FILING Charitable Contributions/Donations.................::cccsssseeeeeees 24

Filing Requirements

Form 500 Instructions

Free Electronic Filing ..

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H@ Qualified taxpayers can file electronically for

Georgia Tax Center.

free!

Georgia Tax Rate Schedule...

™@ Receive your refund by direct deposit!

™@ File fast and securely from your home PC!

Other State's Tax Credit Worksheet...

ON-LINE PAYMENTS

Part-year Resident and Nonresident Instructions...

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Penalty and Interest.

fo Ee) VISA

The Georgia Department of Revenue accepts Visa, American Express, MasterCard, and Discover credit

Requesting an Extension to File

cards for payment of:

Retirement Income Exclusion

Return Filing Tips... ee eee 6

V Current-year and prior-year individual tax payments

Schedule For Estimating Georgia Income Taxes

\ Liabilities on Department of Revenue-issued

Tax Credits.

assessment notices

Taxpayer's Assistance...

\ Individual estimated tax payments

Tax Tables

V Note a convenience fee will be charged by the provider

Where's My Refund

georgia

|Forms in tax booklet: Form 500, Form 500EZ, and Form IND-C!

Follow us on Facebook and Twitter

09

M@ See page 2 for more information on GTC

M@ Check refund status @ Make payments

Visit dor.georgia.gov for more information

about these and other topics of interest.

FROM THE COMMISSIONER

Did you know that by registering an account with the Department of Revenue’s Georgia Tax Center (GTC), you can sign up to receive notifications when any activity takes place on your account? These notifications help you closely monitor your tax status and help combat fraudulent activity. Visit gtc.dor.ga.gov to register. For assistance, you may visit our self-service instructional videos at dor.georgia.gov/georgia-tax-center-help.

Did you also know that taxpayers who file their returns electronically and have their refunds directly deposited into their bank accounts receive their refunds much more quickly than those who filed a paper return. If you’ve been considering electronic filing, some of the benefits include:

a Faster and more accurate processing

a Receiving your refund by mail or direct deposit

a The ability to file from your home PC or have your taxes prepared by a professional electronic return originator

a Elimination of mailing paper returns

The Department of Revenue encourages taxpayers to take time to review and adjust their Georgia income tax withholding if they received a substantial refund last year. By reducing withholding amounts, taxpayers have immediate use of their earnings, and won't have to wait until the following year to get their money. Please use the Form G-4 (or G-4P if you are receiving a pension) to determine your withholding allowances. These forms can be found on the Department's website at dor.georgia.gov.

If you file electronically and need to make a payment, you may pay by electronic check using the Georgia Tax Center. Visit gtc. dor.ga.gov or visit our self-service instructional videos at dor.georgia.gov/georgia-tax-center-help. For additional information contact the Taxpayer Services Call Center at 1-877-423-6711.

The Department of Revenue, as outlined in the Taxpayer Bill of Rights, will provide “fair, courteous and timely service” to the taxpayers of Georgia. We have implemented several initiatives to ensure we uphold that standard. Our mission is to provide the best customer service and operational performance of any state taxing authority. Visit https://dor.georgia.gov/taxpayer-bill-rights to view a copy of the Taxpayer's Bill of Rights.

Robyn A. Crittenden Revenue Commissioner

robyn.crittenden@dor.ga.gov

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Individual Income Tax Online Services

What is the Georgia Tax Center?

The Georgia Tax Center (GTC) is the Department of Revenue’s secure self-service customer facing portal for making online Individual or Business Tax payments and for corresponding with the Department of Revenue.

Who Can Sign Up for GTC? Any individual that has filed an Individual Income Tax Return or would like to submit a Georgia esti- mated tax payment is eligible to use GTC.

GTC Features

You will be able to do the following without a GTC login:

Check refund status

Make quick payments (estimated tax payments or assessment payments) Protest proposed assessments

Request penalty waivers

Submit additional documentation

A login is required to do the following: e Receive notification when a return is filed with your SSN or a refund has been issued Request an Installment Plan Agreement (IPA) Request an Offer in Compromise (OIC) Submit a Power of Attorney (POA) Request to view your 1099-G electronically in GTC View account balance Make payments Perform general account maintenance - address change, preapproval of credits, view credits, etc.

How Do! Sign Up? To use GTC, visit our website at https://gtc.dor.ga.gov. First time users must register before accessing tax accounts. To register, you will need:

e Social Security Number (SSN)

e Federal Adjusted Gross Income (Federal AGI) from the most recent return filed in the State of Georgia

e Avalid e-mail address

Please visit our website to sign up for access to GTC, find helpful links, instructions, and how to videos: dor.georgia.gov/georgia-tax-center-help

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Taxpayer's Assistance and Resources

Find us on the web by going to dor.georgia.gov

e Download Tax Forms e Find Answers to Frequently Asked Questions e Access Where's My Refund e View the Taxpayer's Bill of Rights e Find Georgia Regulations Customer Contact Center: 1-877-423-6711 dor.georgia.gov/individual-taxpayers Get help with: e Refunds e Billing

e Web Access

Helpful Resources and Services

Volunteer Income Tax Assistance (VITA) - dor.georgia.gov/need-help-your-taxes or call 1-800-906-9887

e Free File Alliance visit dor.georgia.gov/free-file-alliance

e AARP - Senior citizens 1-888-AARPNOW (1-888-227-7669) from February 1 to April 15

e Georgia Relay - Deaf and hard of hearing taxpayers (TDD) visit georgiarelay.org

Federal Tax Changes/Conformity, Legislation, and other Policy Information

Visit dor.georgia.gov/rules-policies/income-tax for more information on:

Federal Tax Changes/Conformity with Federal Changes New Legislation

Regulations

Rules and Policies

Georgia did not adopt the revised net operating loss provisions in the 2020 CARES Act and the mod- ification to the Code Section 461(I) limitation in the 2020 CARES Act. As such:

* For losses incurred in taxable years ending after December 31, 2017, there is no carryback and unlimited carryforward of net operating losses and there is a 2 year carryback for farming losses.

* For losses incurred in taxable years beginning on or after January 1, 2018, there is an 80% lim- itation on the usage of net operating losses (the 80% limitation is based on Georgia taxable net income).

* The ILR.C. Section 461(I) adjustment (limitation on losses for noncorporate taxpayers) is required in the same manner as was required before the CARES Act.

* For more information on Georgia's treatment of the Cares Act, see httos://dor.georgia.gov/rules-pol- icies/income-tax/income-tax-federal-tax-changes

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The Department of Revenue has partnered with certain software companies to offer free and/or low cost on- line filing services to Georgia taxpayers under the Free File Alliance Program. Under this agreement, qualified taxpayers can prepare and file their Georgia individual income tax returns for free or a minimum cost using approved software.

Each software company has income limitations and other restrictions for their free services. Please review each company’s offer before selecting a product. For more information, visit our website at dor.georgia.gov/ free-file-alliance.

If you do not qualify for free electronic services, you may file electronically using software produced by an approved vendor listed on our website dor.georgia.gov/ approved-software-vendors.

Volunteer Income Tax Assistance (VITA)

The VITA program was established by the IRS to assist qualified individuals with free electronic tax preparation services. Assistance is geared towards individuals with low to moderate income (less than $55,000 per year). The preparers are IRS-certified and can prepare basic income tax returns. There are several VITA locations in the metro area and throughout Georgia. For more information visit our

website at dor.georgia.gov/need-help-your-taxes.

2-D Barcode

as

The two-dimensional (2D) barcode that appears on your return is the encoded information you entered on your return. This barcode reduces errors and saves time in processing the return. The 2D barcode is only visible after your return has been printed.

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Where's My Refund?

Check the status of your refund online at gtc.dor.ga.gov. You may also check the status of your refund by calling (1-877-423-6711).

Please allow 90 days to receive refunds. The Depart- ment is taking additional fraud prevention measures to ensure tax refunds are issued to the correct individuals.

You will receive your refund via paper check if you are a first time Georgia filer or if you have not filed your taxes in five or more years. This applies for both electronic and paper return filers.

Note: Aclaim for refund must be made within three (3) years from the later of the date the tax was paid or the due date of the return, including extensions.

Payment Options

GTC accepts individual income and estimated tax pay- ments. For information about GTC, visit our website at gtc.dor.ga.gov or visit our self-service instructional

videos at dor.georgia.gov/georgia-tax-center-help.

The Georgia Department of Revenue accepts Visa, American Express, MasterCard, and Discover credit cards as payment for current year individual income tax due on original Forms 500, 500EZ, and 500ES, as well as for liabilities presented to taxpayers via Georgia Department of Revenue assessment notices. To make a payment use, ACI Payments, Inc.'s secure website at acipayonline.com. There is a convenience fee for this service. This fee is paid directly to the company.

For more information on payments, visit our website at dor.georgia.gov/credit-card-payments or contact the Taxpayer Services Customer Contact Center at 1-877- 423-6711.

Installment Payment Agreement. You must meet the following criteria for an installment payment agreement:

@ Returns for all years must be filed

m@ Agreements are up to 60 months

m Payments should be made through automatic debit from your bank account

Note: There is a set up cost associated with initiat- ing an Installment Payment Agreement.

Installment payment requests may be submitted online via the Georgia Tax Center (GTC) at gtc.dor.ga.gov. Please contact the Installment Payment Agreement Section at 404-417-2122 or via e-mail to installment. payment@dor.ga.gov to determine eligibility. For more information on Installment Payment Agreements, visit our website at https://dor.georgia.gov/installment-agree- ments-faq.

Mailing Address Tax Returns

Form 500 without payment: Form 500 with payment:

PROCESSING CENTER PROCESSING CENTER

GEORGIA DEPARTMENT OF REVENUE GEORGIA DEPARTMENT OF REVENUE PO BOX 740380 PO BOX 740399

ATLANTA GA 30374-0380 ATLANTA GA 30374-0399

Form 500X Amended:

PROCESSING CENTER

GEORGIA DEPARTMENT OF REVENUE PO BOX 740318

ATLANTA GA 30374-0318

Payments without Return Form 500-ES Individual Estimate Tax Voucher PROCESSING CENTER GEORGIA DEPARTMENT OF REVENUE PO BOX 740319 ATLANTA GA 30374-0319

Form 525-TV Payment Voucher

Note: If you filed electronically and making a payment by check PROCESSING CENTER

GEORGIA DEPARTMENT OF REVENUE

PO BOX 740323

ATLANTA GA 30374-0323

Form IT-560 Extension Payment Voucher PROCESSING CENTER

GEORGIA DEPARTMENT OF REVENUE PO BOX 105198

ATLANTA GA 30348-5198

Note: Sending your return by certified mail delays the processing of your return and your refund.

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Filing Checklist

™ Consider filing my return electronically. It is safe and convenient to file electronically. Interested in filing electronically visit dor.georgia.gov/why-should-i-file-electronically

@ Are Social security number(s) on the return accurate and complete? @ Added all the dependents' information, if applicable @ Checked math and calculations = Rounded to the nearest dollar ™@ Selected the correct amounts from the IT-511 tax table

™ Completed the Income Statement Detail section where Georgia income tax was withheld. At- tach Forms W-2s, 1099s, and G2-RPs, only if Georgia tax was withheld on these forms.

™@ Signed and dated my return = Both spouses signed the joint return, even if there was only one income

= Note: Anyone paid to prepare the return must also sign it ™@ Completed and included all schedules and IND-CRs that are applicable

= Note: Schedule 2 credits must be filed electronically @ Mailed my return to the correct address

Dos and Don'ts For Filing Paper Returns

Do @ Do include your W-2(s), 1099(s), GR-2P(s) and other supporting income statements @ Docomplete the Income Statement Details section for Georgia tax withheld

m@ Paper Filing: Do send your return, check/money order, and 525-TV voucher to the address on the return

™@ Do use GTC or the Form IT-560 to make an extension payment

m@ Do make your check or money order payable to the Georgia Department of Revenue Don't

@ Do not include cents on your return

™@ Do not staple your W-2(s), 1099(s) and other forms to your return

@ Do not use the Form 500 to correct a previously filed return - Use Form 500X Note: Sending your return by certified mail delays the processing of your return and your refund.

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GENERAL INFORMATION

What's New

= Adoption of a Foster Child Credit (IND-CR 208)

This credit now applies to adoptions occurring in taxable years beginning on or after January 1, 2008 and before

January 1, 2021. For more information see IND-CR 208

for more details.

= Adoption of a Foster Child Credit (IND-CR 213): There is a new credit for adoptions occurring in taxable years beginning on or after January 1, 2021. For more information see IND-CR 213 for more details.

@ Historic Rehabilitation Tax Credits: These credits have been revised, for more information, see https:// dor.georgia.gov/tax-credit-summaries.

™@ Taxpayer and/or Spouse Date of Death: The person filing the return should provide the date of death for the taxpayer and/or spouse, if applicable, in the space provided on the form.

™ Standard Deductions: The standard deductions have been increased for the next tax year 2022. For more information see the 2022 Form 500-ES instructions.

When to File. Calendar year taxpayers are required to file on or before April 18, 2022. Fiscal year taxpayers must file on or before the 15th day of the fourth month after the close of their taxable year.

Extension to File. The Georgia return must be filed along with a copy of Federal Form 4868 or the IRS confirmation letter on or before the extended Federal due date. If you do not need a Federal extension, you may use Georgia Form IT 303 to request an extension to file your Georgia return.

An extension to file does not extend the date for paying the tax. Taxes must be paid electronically via GTC or with Form IT-560 by the statutory due date to avoid late payment penalty and interest. The amount paid should be entered on Form 500, Line 25.

Amended Returns. File Form 500X to correct information reported on Form 500. Do not use Form 500 to correct a previously filed return or use Form 500X as an original return.

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When Electronic Filing is Required. Taxpayers that remit payments by electronic funds transfer, whether on a mandatory or voluntary basis, must file all associated returns electronically.

A return preparer who prepares an income tax return, must electronically file the return, when the federal counterpart of such return is required to be filed elec- tronically pursuant to the Internal Revenue Code of 1986 or Internal Revenue Service regulations.

Also, a return is required to be electronically filed if the return generates, allocates, claims, utilizes, or includes in any manner a series 100 tax credit. (see page 21)

Penalty and Interest. Tax not paid by the statutory due date of the return is subject to interest and % of 1 percent late payment penalty per month, or fraction thereof. Also, a monthly late filing penalty is imposed at a rate of 5 percent of the tax not paid by the original due date. Interest accrues until the tax due has been paid in full. The combined total of late filing and late payment penalty cannot exceed 25 percent of the tax not paid by the original due date. An extension of time for filing the return does not extend the date for making the payment. Additional penalties may apply as follows:

@ Frivolous Return Penalty - $1,000. (A frivolous return is one that contains incorrect or insufficient information to accurately compute the appropriate tax liability with the intent to delay or impede Georgia tax law or is based on a frivolous position.)

@ Negligent Underpayment Penalty - 5 percent of the underpaid amount.

@ Fraudulent Underpayment Penalty - 50 percent of the underpaid amount.

@ Failure to File Estimated Tax Penalty - 9 percent per year for the period of underpayment. Use Form 500 UET to calculate the penalty.

@ Interest accruing for months beginning before July 1, 2016 accrues at the rate of 12 percent annually. Interest that accrues for months beginning on or after July 1, 2016 accrues as provided by Georgia Code Section 48-7-81.

Assessments. If your return is reviewed and it is deter- mined that you owe additional taxes, generally, you will be issued a Proposed Assessment. Once a Proposed Assessment is issued, you have 30 days to complete a protest on the Georgia Tax Center (GTC) website. After 30 days, the Department will issue an Official Assess-

GENERAL INFORMATION

ment and Demand for Payment. You have 30 days to file an appeal with either the Georgia Tax Tribunal or in the appropriate Superior Court. For more information and the Taxpayer Bill of Rights, see the Department’s

website at dor.georgia.gov.

Supporting Documents. We will request information to support the amounts listed on your Georgia income tax return and related schedules when necessary. However, in addition to withholding statements (W-2s,1099s, G2- RPs, etc.) where taxes were withheld you must include the following documentation with your Georgia return when it is filed for the following situations:

Hm The amount on Form 500, Line 8 is $40,000 or more, or less than the total income on your W-2(s) - submit a copy of Pages 1, 2, and Schedule 1 of your Federal return (the Federal Schedule 1 must be included if a copy was submitted with your federal return).

m@ You itemize deductions - submit a copy of Federal Form 1040 Schedule A.

@ You claim the Georgia child and dependent care expense credit - submit the appropriate Federal child care credit schedule.

@ You claim a credit for taxes paid to another state(s)- submit a copy of your return filed with the other state(s).

Address Changes. You must notify the Department of your address change. Notification of an address change can be made through GTC inside a logon, by calling 1-877-423-6711 or writing the new address on your tax return and checking the address change box.

Name Change. The Department currently requires a copy of one of the following four documents in order to change a person’s name:

. Social Security Card

. Driver’s License

. Name change decree from Superior Court . Marriage Certificate

These documents should be submitted with your tax return.

Innocent Spouse Relief. Individuals who were granted innocent spouse relief by the Internal Revenue Service may be eligible for relief from liability for Georgia tax,

interest and penalty. page 8 age

Individual Retirement Accounts. The provisions concerning taxability and conversion from a traditional IRA to a Roth IRA are the same for Georgia and the Internal Revenue Service.

Withholding on Lump-sum Distributions. The payee of any non-periodic payment may elect to have withholding made on the non-periodic distributions from a pension, annuity, or similar fund. The election shall remain in effect until revoked by the payee. See Form G-4P for more information.

Income from Partnerships and S Corporations. Nonresident partners must pay Georgia income tax on their portion of the partnership’s Georgia income. Nonresident shareholders must pay Georgia income tax on their portion of the S Corporation's Georgia income; resident shareholders and partners must report their total S Corporation or partnership income (but may be eligible for the credit for taxes paid to other states or a subtraction when the income is taxed at the entity level in Georgia or another state).

Federal Audit. Whenever a Federal audit or other Federal adjustment results in a change in net income for any year, you are required to furnish under separate cover, within 180 days, a schedule reflecting all changes. Please include the schedule when you file form 500X. Additionally, if the changes result in a refund, the refund must be claimed within one year of the date the changes are submitted. If you do not submit a return reflecting all changes and the Commissioner receives this information in a report from the United States Government, the Commissioner will issue an assessment for tax due within five years from the date the report is received from the United States Government.

A taxpayer who fails to notify the Commissioner within 180 days forfeits any Georgia refund as a result of an IRS audit if the normal statute of limitations has expired. However, 90 percent of any overpayment can be applied to a balance due for another year that is a result of the same IRS audit.

Withholding on Nonresidents. Withholding is required on the members share of the taxable income sourced to this state, whether distributed or not, from Partnerships, Limited Liability Companies and S Corporations. With- holding should be reported on Form G2-A and entered on Form 500, Line 24. Include a copy of Form G2-Awith your return.

Withholding is also required on the sale or transfer of real property and associated tangible personal property

FILING REQUIREMENTS

by nonresidents of Georgia. Tax withheld is reported on Form G2-RP and should be entered on Form 500, Line 24. Include a copy of Form G2-RP with your return.

Full-year Residents

Full-year residents are taxed on all income, except tax exempt income, regardless of the source or where derived. You are required to file a Georgia income tax return if:

m You are required to file a Federal income tax return;

m You have income subject to Georgia income tax that is not subject to Federal income tax;

m Your income exceeds the standard deduction and personal exemptions as indicated below:

A. Single, Head of Household or Qualifying Wid- ow(er) 1. Under 65, not blind 2. Under 65, and blind 3. 65 or over, not blINd.......... eee $8,600 4. 65 or over, and blind.....0...0e ee $9,900 B. Married filing Joint

1. Both under 65, not blind $13,400 2. One 65 or over, not blind.. ..$14,700 3. Both under 65, both blind $16,000 4. Both under 65, one blind...................... $14,700 5. Both 65 or over, not blind...................... $16,000 6. One 65 or over, and blind...................... $16,000 7. One 65 or over, and both blind.............. $17,300 8. Both 65 or over, and blind..................... $18,600

C. Married filing Separate 1. Under 65, not blind. 2. Under 65, and blind 3. 65 or over, not blind... 4. 65 or over, and blind..

These requirements apply as long as your legal resi- dence is Georgia, even if you are absent from or live outside the State temporarily. A credit for taxes paid to another state is allowed. See the worksheet on page 19 for more information.

Part-year and Nonresidents

1. Part-year residents and nonresidents who work in Georgia or receive income from Georgia sources are required to file Georgia Form 500 and complete Form 500 Schedule 3 to calculate Georgia taxable income. Note: Form 500 Schedule 3 should only be attached if

it is applicable. Page 9

2. A married part-year resident or nonresident with income earned in Georgia whose spouse is a nonresident with no Georgia source income may file either a separate return claiming only their own personal exemption and dependent exemptions and deductions or a joint return claiming total allowable deductions.

3. If one spouse is a resident and one is a part-year resident or nonresident, enter 3 in the residency status box and complete Form 500, Schedule 3 to calculate Georgia taxable income.

Part-year Residents

1. If you are a legal resident of Georgia for only a portion of the tax year and are required to file a Federal income tax return, you are required to file a Georgia income tax return.

2. Part-year residents who claim a credit for taxes paid to another state for income earned while a resident must include a copy of the individual income tax return filed with that state(s) with their Georgia return. Otherwise the credit will not be allowed.

Nonresidents

1. Nonresidents who work in Georgia or receive income from Georgia sources and are required to file a Federal return are required to file a Georgia income tax return.

2. Legal residents of other states are not required to file a Georgia tax return if their only activity for financial gain or profit in Georgia consists of performing services for an employer as an employee where the wages for such services does not exceed the lesser of five percent of the income received from performing services in all places during the taxable year or $5,000.

3. Anonresident, who receives deferred compensation or income from the exercise of stock options that were earned in Georgia in a prior year is required to pay tax on the income, but only if the prior year’s income exceeds the lesser of: 1) 5 percent of the income received by the person in all places during the current taxable year; or 2) $5,000. However, the income is not taxed if federal law prohibits the state from taxing it. Federal law prohibits state taxation of some types of retirement income including pensions as well as income received from nonqualified deferred compensation plans if the income is paid out over the life expectancy of the person or at least 10 years. See Regulation 560-7-4-.05 for more information.

FILING REQUIREMENTS

Taxpayers Required to File Form 1040NR

Individuals who are required to file Federal Form 1040NR must file Georgia Form 500. Similar to Federal income tax rules, most of these Georgia taxpayers are only allowed to deduct the applicable Georgia personal exemption and expenses reflected on Form 1040NR. Most taxpayers are not allowed to take the standard deduction and are allowed only limited itemized deductions as shown on Form 1040NR, Schedule A.

Military Personnel

Residents. Military personnel who are legal residents of Georgia are subject to Georgia income tax on all income regardless of the source or where earned, unless specifically exempt by Georgia law. Military personnel who serve outside of the continental U.S. may file their Georgia income tax return within six months after they come back to the continental U.S. No penalties or interest will accrue during this period. Members of the National Guard or Air National Guard who are on active duty for a period of more than 90 consecutive days are allowed a tax credit against their individual income tax. The credit cannot exceed the amount expended for qualified life insurance premiums or the taxpayer’s income tax liability and should be claimed on Form IND-CR.

Nonresidents. Military personnel who are not legal residents of Georgia are only required to file a Georgia income tax return if the person earns income during their off duty hours from sources in Georgia or if the person has income from property located in Georgia or the person receives business income from Georgia sources. If required, nonresident military personnel should file Georgia Form 500 and use Schedule 3 to calculate Georgia taxable income. (See pages 17 -18 for instructions on completing Schedule 3.)

Spouses of Military Personnel. Aspouse of a military person shall neither lose or acquire their legal residence solely to be with the military person serving in compliance with military orders but this provision only applies if the legal residence of the spouse is the same as the military person or the spouse of a military person has elected to use the same residence for purposes of taxation as the military person. Income for services performed by the spouse of a military person shall not be considered Georgia income if the military person is not a legal resident of Georgia but this only applies if the spouse is in Georgia solely to be with the military person serving in compliance with military orders and the legal residence of the spouse is the same as the military person or the spouse of a military person has elected to use the same residence for purposes of taxation as the military person. The affected taxpayer should exclude the income on Schedule 3, Column C, Line 7 of the Form 500. No amounts should be entered on Schedule 3, Column A, Line 7 of Georgia Form 500.

Combat Zone Pay

Military income earned by a member of the National Guard or any reserve component of the armed services while stationed

Page 10

in a combat zone or stationed in defense of the borders of the United States pursuant to military orders is not subject to Georgia income tax. The exclusion from income is only with respect to military income earned during the period covered by such military orders. A copy of the Federal return must be enclosed with the Georgia return to claim this exclusion. The exclusion is limited to the amount included in Federal Adjusted Gross Income.

Estimated Tax

Estimated tax is required for each individual subject to Georgia income tax who reasonably expects to have gross income during the year which exceeds (1) personal exemption, plus (2) credits for dependents, plus (3) estimated deductions, plus (4) $1,000 of income not subject to withholding.

Estimated tax required from persons not regarded as farmers or fishermen shall be filed on or before April 15 of the taxable year, except if the above requirements are first met on or after April 1 and before June 1, estimated tax must be filed by June 15; on or after June 1 but before September 1, by September 15; and on or after September 1, by January 15 of the following year. Individuals filing on a fiscal year basis ending after December 31 must file on corresponding dates.

Other State’s Tax Return

If you claim a credit for taxes paid to another state(s), you must include a copy of your return filed with that state along with your Georgia return. No credit for taxes paid to another state will be allowed unless the other state’s return is enclosed with the Georgia return.

Filing for Dependents (children, etc.)

If the parent or guardian prepared the minor child or dependent’s return, the Department recommends that the parent or guardian check the box allowing the preparer to discuss the return with the Department. If this is not done and the parent did not sign the return on the child's behalf as allowed by IRS Publication 929, then the parent or guardian will have to be included on a Power of Attorney (Form RD- 1061) prepared by the minor in order for the Department to discuss the return with the parent or guardian.

Filing for Deceased Taxpayers

The surviving spouse, administrator, or executor may file a return on behalf of a taxpayer who dies during the taxable year. When filing, use the same filing status that was used on the Federal income tax return. The due date for filing is the same as for Federal purposes.

Note: To have a refund check in the name of a deceased taxpayer reissued, mail Georgia Form GA-5347, a copy of the death certificate, and the information specified on Georgia Form GA-5347 along with the check to the address on the form.

FORM 500 INSTRUCTIONS

Include all completed schedules with your Georgia return.

Complete your Federal return before starting your Georgia return. Your Federal return contains information that should

be included on your Georgia return.

Lines 1 - 3: Print or type your name(s), address (includ- ing apartment number if applicable) and social security number(s) in the spaces provided. Do not write both a street address and post office box in the address field.

Line 4: Enter the appropriate number for your residency status.

m 1 - You lived in Georgia the entire year, regardless of temporary living arrangements.

m 2- You lived in Georgia part of the year. Note: List the dates you lived in Georgia and you must complete Schedule 3 to calculate Georgia taxable income.

m@ 3 - You did not live in Georgia or if one spouse is a resident and one is a part-year resident or nonresident. Note: You must complete Schedule 3 to calculate Georgia taxable income.

Line 5: Enter the appropriate letter for your filing sta-

tus. Use the same status that is on your Federal return. m A- Single

B - Married filing joint;

C - Married filing separate;

D - Head of Household or Qualifying widow(er)*

*Use filing status D if your filing status is qualifying widow(er) on your Federal return.

Georgia recognizes same sex marriage.

Exceptions:

m™ One spouse is a resident and the other is a nonresident without any Georgia-source income, your Georgia return may be filed jointly or separately with each spouse claiming the appropriate exemptions and deductions.

Line 6a - 6b: Check the appropriate box —™ 6a for yourself —™ 6b if you claim your spouse and you file jointly.

Line 6c: Enter the total number of exemption boxes checked.

Lines 7a - b: Exemptions and Dependents

™@ 7a: Enter the total number of dependents. Do not include yourself or your spouse. A dependent is determined in the same manner as was determined when dependents were allowed for Federal income tax purposes. If married filing separate, only one spouse may claim the dependent and the prior Federal rules (those when dependents were allowed) are used to determine who is entitled to claim the dependent. | 7b: List the requested information about your dependents in the spaces provided. Include a schedule if you have more than four dependents.

Line 8: Enter Federal adjusted gross income from Form 1040. Do not use Federal taxable income.

Page 11

Note: If the amount on Form 500, Line 8 is $40,000 or more, or less than the total income on your W-2s you must submit a copy of your Federal Form 1040 pages 1, 2 and Schedule 1.The Federal Schedule 1 must be included if a copy was submitted with your federal return.

Line 9: You must adjust your Federal adjusted gross income if you have income that is taxable by the Federal Government but not taxable to Georgia or vice versa. You must document your adjustments on Schedule 1 and enter the total amount here. There are certain adjustments that must be added if applicable and some adjustments that may be subtracted. Please see pages 14 - 16 for more information about additions and subtractions.

Note: Part-year residents and nonresidents must omit Lines 9 -14 and follow the Schedule 3 instructions that begin on page 17.

Line 10: Enter Georgia adjusted gross income (net total of Line 8 and Line 9).

Lines 11a-c: Standard Deductions (Leave Lines 11a-c blank if you itemize deductions)

Note: If you use the standard deduction on your Federal return, you must use the Georgia standard deduction on your Georgia return.

Line 11a: Enter the standard deduction that corresponds to your marital status. @ Single/Head of Household/Qualifying Widow(er)............ $4,600 @ Married Filing Separate.. .. $3,000 @ = Married Filing Joint. = Additional Deduction...

Line 11b: Enter any additional deductions on Line 11b.

Note: The additional deduction applies if you and/or your spouse are age 65 or over and/or blind.

Line 11c: Enter the total standard deduction on Line 11c.

Lines 12a-c: Itemized Deduction (Leave Lines 12a-c blank if you use the standard deduction)

Note: If you itemize deductions on your Federal return, or if you are married filing separate and your spouse itemizes deductions, you must itemize deductions on your Georgia return. Include a copy of Federal Schedule A with your Georgia return.

Line 12a: Enter the itemized deductions from your Federal Schedule A.

Line 12b: Enter adjustments for income taxes other than Georgia and investment interest expense for the production of income exempt from Georgia tax.

FORM 500 INSTRUCTIONS (continued)

Line 12c: Subtract Line 12b from Line 12a, enter total.

Note: For all taxpayers (full year, part year, and nonresident), if state & local income taxes were limited on the federal return to $10,000 ($5,000 MFS), the following formula should be used to determine the disallowed other state income taxes: Other state income taxes divided by the total taxes on line 5d of schedule A multiplied by the lesser of the amount on line 5d of schedule A or $10,000 ($5,000 if married filing separate). For part year and nonresidents on the schedule 3, the same computation should be used in arriving at the amount of itemized deductions that would then be subject to proration using the part-year/nonresident income ratio on form 500 schedule 3 line 9.

Line 13: Subtract Line 11c or 12c from Line 10, enter total.

Lines 14a-c: Exemption and Dependent Totals

Lines 14a: Multiply the number of exemptions on Line 6c by the filing status totals listed below and enter the total.

@ $2,700 for filing status: A - Single or D - Head of Household or Qualifying Widow(er)

= $3,700 for filing status: B - Married Filing Joint or C - Married filing separate

Line 14b: Multiply the number of dependents Line 7a by $3,000 and enter the total.

Line 14c: Enter the grand total of Lines 14a and 14b.

Line 15a: Subtract Line 14c from Line 13 (or enter Sch 3, Line 14) to get your Georgia taxable income before GA Net Operating Losses (NOLs).

Line 15b: Georgia NOL Utilized

Net operating losses (NOLs) for tax years 2018 and later that are applied to Georgia income cannot exceed 80% of Georgia income before NOLs. Use the schedule below to compute the net operating losses that can be used in the current year.

1. NOL carry forward available for current year from years before 2018

2. NOLcarry forward available for current year from years 2018 and later

3. Income before GA NOL (Line 15a of Form 500) 4. NOL from line 1 applied to current year

5. NOL from line 2 applied to current year (cannot exceed 80% of Line 3)

6. Total NOL applied - add Lines 4 and 5, also enter on Line 15b of Form 500

Note: Before determining how much NOL can be carried from the current year to the next year, the income from the current year must be recomputed using the "Net Operating Losss Carryover" schedule and the related instructions on Form 500-NOL.

Line 15c: Subtract Line 15b from Line 15a.

Line 16: Take the amount from Line 15c and find the Page 12

corresponding amount and your filing status on the tax tables in this booklet or use the rate schedule on page 49 to determine your tax liability.

Line 17: Complete the Low Income Credit Worksheet on page 20 to determine your credit amount. Enter the amount from Line 6 of the worksheet on the form.

Note: You may claim the low income credit if your Federal adjusted gross income is less than $20,000 and you are not claimed or eligible to be claimed as a dependent on another taxpayer’s Federal or Georgia income tax return. Part-year residents may only claim the credit if they were residents at the end of the tax year. Taxpayers filing a separate return for a taxable year in which a joint return could have been filed can only claim the credit that would have been allowed had a joint return been filed. You cannot claim this credit if you are an inmate in a correctional facility. This credit must be claimed on or before the end of the 12th month following the close of the tax year. The credit cannot exceed the taxpayer’s income tax liability.

Line 18: Enter the other state(s) tax credit used. If you paid tax to more than one state, use the total of the other state’s income and the worksheet on page 19 to calculate the Other State’s Tax Credit.

Note: You must include a copy of the return filed with the other state(s) with your Georgia return or the credit will not be allowed.

Line 19: Enter the amount of credits used from the last line of the IND-CR Summary Worksheet. IND-CR forms are included within the form.

Line 20: Enter the amount of credits used from Schedule 2. The return must be filed electronically if series 100 tax credits are claimed or generated. If claiming credit code 125 (QEE) enter your SSN and not the FEIN of the SSO. See page 21 for more information regarding credits.

Line 21: Add Lines 17-20 to get the amount for total credits used. Amount cannot exceed Line 16.

Line 22: Subtract Line 21 from Line 16. enter zero.

If zero or less,

Line 23: Enter Georgia income tax withheld from W-2s and 1099s where Georgia income tax was withheld.

Note: Include a copy of these statements with your return or this amount will not be allowed.

Line 24: Enter Georgia income tax withheld on G2-A, G2-FL, G2-LP, and/or G2-RP. Include a copy of these statements with your return or this amount will not be allowed.

Note: Please complete the Income Statement Details Section. Only report income on which Georgia tax was

FORM 500 and SCHEDULE 1 INSTRUCTIONS (continued)

withheld. Enter income form W-2s, 1099s, and G-2As on Line 4 GA Wages/Income. For other statements complete Line 4 using the income reported from Form G2-RP Line 12 or Line 13; Form G2-LP Line 11, or for Form G2-FL enter zero.

Line 25: Enter estimated tax payments, including amounts credited from a previous return, and any payments made electronically or with Form IT 560.

Line 26: Enter Schedule 2B Refundable Tax Credits. The return must be filed electronically to claim these credits.

Line 27: Add Lines 23, 24, 25, and 26 and enter the total amount.

Line 28: If Line 22 is more than Line 27, subtract Line 27 from Line 22 to calculate the balance due.

Line 29: If Line 27 is more than Line 22, subtract Line 22 from Line 27 to calculate your overpayment.

Line 30: Enter the amount you want credited to next year's estimated tax.

Lines 31 - 39: Enter the amount you want to donate to the charities listed on the form.

Note: Amount cannot be less than $1.

Line 40: Enter the estimated tax penalty from Form 500 UET. If you were eligible for an estimated tax penalty exception on Form 500 UET, please check the “500 UET Exception Attached” box, include the revised penalty on line 40 of the Form 500, and include the 500 UET with the return.

Note: If the revised penalty is zero, enter zero.

Line 41: Add Lines 28 and 31 through 40 and enter the total amount due. Mail your return, 525-TV payment voucher, and payment to the address on the Form 500.

Line 42: Subtract the sum of Lines 30 through 40 from Line 29 and enter the amount to be refunded to you.

Direct Deposit Option

Note: If you do not enter Direct Deposit Information or if you are a first time Georgia filer or if you have not filed your taxes in five or more years you will receive your refund via paper check. This applies both to electronic and paper return filers.

Line 42a: Complete the direct deposit information

™ Check the appropriate box (Checking or Savings) for the type of account. Note: Do not check more than one box. You must check

the correct box to ensure your direct deposit is accepted.

m@ Enter your nine digit routing number. Note: The first two digits must be 01 through 12 or 21 through 32.

Ask your financial institution for the correct routing number to enter on line 42a if:

* The routing number on a deposit slip is different from the routing number on your checks.

* The deposit is to a savings account that does not allow you to write checks or

* Your checks state they are payable through a financial institution different from the one at which you have your checking account.

m@ Enter your account number from left to right and leave unused boxes blank. Include hyphens, but omit spaces and special symbols. Note: The account number can be up to 17 characters (both numbers and letters).

Example

On the sample check below, the routing number is 807100013. John Doe would use that routing number unless their financial institution instructed them to use a different routing number for direct depos- its. The account number is 978653421. Do not include the check number. On the sample check above, the check number is 5678.

Account Member Ie 1

Routing Humber i

J iT TT T GHOMOOOLIGITAR SIL ke

Direct Deposit Rejects If any of the following apply, your direct deposit request will be re- jected and a check will be mailed:

m@ Any numbers or letters are crossed out or whited out. @ = Aninvalid checking, savings, or routing number was entered.

@ Your financial institution will not allow a joint refund to be depos- ited to an individual account. The State of Georgia is not responsible if a financial institution rejects a direct deposit.

m™ You request a deposit of your refund to an account that is not in your name (such as your tax preparer’s own account).

Signature Section

Please sign and date your return. If filing a joint return you and your spouse must sign and date the return. If applicable, the paid preparer should also sign the return. If the taxpayer and/or spouse is deceased, check the "Deceased checkbox" and provide the date of death.

Page 13

SCHEDULE 1 ADDITIONS AND SUBTRACTIONS

Schedule 1 Instructions Lines 1 - 6: Enter your additions to income (see page 14 Additions section for detailed information).

Lines 7 - 13: Enter your subtractions from income (see pages 14 - 16 Subtractions section for detailed information).

Lines 14: Enter your total net adjustments here and on Line 9 of page 2 of Form 500.

Note: Please complete and include your Retirement In- come Exclusion calculation (Page 2 of Schedule 1), if you entered information on Schedule 1, Lines 7 a and/or b.

Additions

The following adjustments must be added if applicable 1. Interest received from non-Georgia municipal bonds and dividends received from mutual funds that derived income from non-Georgia municipal bonds. These may only be reduced by direct and indirect interest expenses which are attributable to the income and which have not already been deducted in arriving at Federal adjusted gross income or itemized deductions.

2. Loss carryovers from years when you were not subject to Georgia income tax.

3. Lump sum distributions from employee benefit plans reported on IRS Form 4972.

4. Depreciation because of differences in Georgia and Federal law during tax years 1981 through 1986.

5. Adjustments due to Federal tax changes (see dor. georgia.gov/rules-policies/income-tax/income-tax-federal-

tax-changes).

6. Net operating loss carryover deducted on federal return.

7. Payments for more than $600 in a taxable year made to employees which are not authorized employees and which are not excepted by Code Section 48-7-21.1. An authorized em- ployee is someone legally allowed to work in the United States.

8. Taxable portion of withdrawals on the Path2College 529 Plan (see Regulation 560-7-4-.04).

9. For the qualified education expense credit, the deduction relating to the credit. See Regulation 560-7-8-.47.

10. For the Land Conservation credit, the deduction re- lating to the credit. See Regulation 560-7-8-.50 for more information.

11. For the qualified rural hospital organization expense tax credit, the deduction relating to the credit. See Regulation 560-7-8-.57 for more information.

12. For the qualified education donation tax credit, the de- duction relating to the credit. See Regulation 560-7-8-.60 for more information.

Note: If the contribution relating to the above credits is treat- ed as a deduction of state taxes, then the following formula should be used to determine the disallowed state income

Page 14

taxes: Contribution treated as state income taxes divided by the total taxes on line 5d of schedule A multiplied by the lesser of the amount on line 5d of schedule A or $10,000 ($5,000 if married filing separate).

Note: Also, for both other state income taxes and when the contribution relating to the above credits is treated as a de- duction of state taxes, the federally taxable state income tax refund that is later received may be eligible to be reduced. The reduction equals the federally taxable refund times the proportion that was used to figure out how much of the deduction had to be reduced in the year of the deduction (Contribution treated as state income taxes divided by the total taxes on line 5d of schedule A).

Note: If ataxpayer receives a state refund and is not required to include the refund in Federal AGI since they were subject to Federal Alternative Minimum Tax, they are not required to include the refund for Georgia purposes.

Note: Georgia does not allow the 20% qualified business income deduction. (I.R.C. Section 199A). However, since Georgia starts with Federal AGI, no adjustment is necessary on the Georgia return.

Subtractions The following adjustments may be SUBTRACTED: 1. Retirement income. The maximum retirement in- come exclusion is $35,000 for taxpayers who are: (A) 62 - 64 years of age, or (B) less than 62 and permanently disabled to such an extent that they are unable to perform any type of gainful employment The retirement exclusion is $65,000 if the taxpayer is 65 or older.

The exclusion is available for the taxpayer and his/her spouse; however, each must qualify on a separate basis. If both spouses qualify, each spouse may claim the amounts above. Income from property that is jointly owned should be allocated to each taxpayer at 50% of the total value. Up to $4,000 of the maximum allowable exclusion may be earned income. Use the instructions on page 16 and complete Form 500, Schedule 1, Page 2.

2. Interest and dividends on U.S. Government bonds and other U.S. obligations. These must be reduced by direct and indirect interest expenses which are attributable to the income. Note:Interest received from the Federal National Mortgage Association, Government National Mortgage Association, Federal Home Loan Mortgage Corporation, and from repurchase agreements is taxable and should not be subtracted.

3. Social security or railroad retirement (tier 1 and tier 2) paid by the Railroad Retirement Board included in Federal adjusted gross income.

4. Salaries and wages reduced from Federal taxable income because of the Federal Jobs Tax Credit.

5. Individual retirement account, Keogh, SEP and SUB-S plan withdrawals where tax has been paid to Georgia because of the difference between Georgia and Federal law for tax years 1981 through 1986.

Schedule 1 Subtractions (continued)

6. Depreciation because of differences in Georgia and Federal law during tax years 1981 through 1986.

7. Dependent’s unearned income included in parents’ Federal adjusted gross income.

8. Income tax refunds from states other than Georgia included in Federal adjusted gross income. Do not subtract Georgia income tax refunds.

9. Income from any fund, program or system which is specifically exempted by Federal law or treaty.

10. Adjustment to Federal adjusted gross income for Georgia resident shareholders for Subchapter S income where the Sub S election is not recognized by Georgia or another state or for Georgia resident partners in a partnership or members in an LLC where such entities' income has been taxed at the entity level by another state.

This adjustment is only allowed for the portion of income on which the tax was actually paid by the corporation or partnership to another state(s).

The subtraction amount is calculated as follows:

1. Determine the Georgia taxable net income received from the entity. This should include any income, gains, losses and deductions from the entity which are separately reported and included on the taxpayer's return including any guaranteed payments received from a partnership. This does not include wages paid to the partner, shareholder, or member. However, if such wages are taxed by another state, the partner, shareholder, or member may be eligible for the other state(s) tax credit.

2. Multiply the above income by the entity's apportionment ratio in such other state.

Only states which have a tax on the entity which is on or measured by income are eligible for the subtraction. Income subject to the Texas Margin Tax is eligible for this subtraction. Please see Code Section 48-7-27(d) and Regulation 560-7-4- .01 for more information.

In cases where the Sub S election is recognized by another state(s) the income should not be subtracted. Credit for taxes paid to other states may apply.

11. Adjustment for teachers retired from the Teacher's Retire- ment System of Georgia for contributions paid between July 1, 1987 and December 31, 1989 that were reported to and taxed by Georgia.

12. Amount claimed by employers in food and beverage estab- lishments who took a credit instead of a deduction on the Federal return for FICA tax paid on employee cash tips.

13. An adjustment of 10% of qualified payments to minority subcontractors or $100,000, whichever is less, per taxable year by individuals, corporations or partnerships that are party to state contracts. For more information call the Department of Administrative Services at 404-657-6000 or visit their website: http://doas.ga.gov/state-purchasing/suppliers

14. Deductible portion of contributions to the Path2College 529 Plan. The deduction is limited on a return to the amount contributed but cannot exceed $4,000 per beneficiary unless a married filing joint return is filed then the amount cannot exceed

$8,000 per beneficiary.

15. Adjustments due to Federal tax changes (see dor.georgia. gov/rules-policies/income-tax/income-tax-federal-tax-changes).

16. Combat zone pay exclusion. See page 10 for more information.

17. Up to $10,000 of unreimbursed travel expenses, lodging ex- penses and lost wages incurred as a direct result of a taxpayer's donation of all or part of a kidney, liver, pancreas, intestine, lung or bone marrow during the taxable year.

18. An amount equal to 100 percent of the premium paid by the taxpayer during the taxable year for high deductible health plans as defined by Section 223 of the Internal Revenue Code. The amount may only be deducted to the extent the deduction has not been included in federal adjusted income and the expenses have not been provided from a health reimbursement arrangement and have not been included in itemized deductions. In the event the taxpayer claims the expenses as itemized deductions, the taxpayer should multiply the expense by the ratio of total allowed itemized deductions after the federal limitation to the total allowed itemized deductions before the federal limitation to determine the amount that is not allowed to be deducted pursuant to this paragraph. For example, the taxpayer has $1,000 in high deductible health insur- ance premiums. They also have $7,000 of other medical expenses which means they have total medical expenses of $8,000. After the limitation, the taxpayer is only allowed to deduct $2,000 of medical expenses. The $1,000 deduction must be reduced by $250 ($2,000/$8,000 x $1,000). Which means the taxpayer is allowed to deduct $750 pursuant to this paragraph.

19. Federally taxable interest received on Georgia municipal bonds designated as “Build America Bonds” under Section 54AA of the Internal Revenue Code of 1986. “Recovery Zone Economic Development Bonds” under Section 1400U-2 of the Internal Rev- enue Code or any other bond treated as a ‘Qualified Bond” under Section 6431(f) of the Internal Revenue Code are considered “Build America Bonds” for this purpose.

20. Federally taxable interest received on Georgia municipal bonds issued by the State of Georgia and certain authorities or agencies of the State of Georgia for which there is a special exemption under Georgia law from Georgia tax on such interest.

21. Interest eliminated from federal itemized deductions due to the Federal Form 8396 credit.

22. An amount equal to 100 percent of the payments made to and received by a disabled first responder pursuant to Code Section 45- 9-85 (Payment of indemnification for death or disability) provided that and to the extent such amounts are included in the taxpayer's federal adjusted gross income and are not otherwise exempt from the tax imposed by this article under any other provision of law. The term ‘disabled first responders' means a law enforcement officer, fireman, publicly employed emergency medical technician, or a surviving spouse of such an individual, receiving payments pursuant to Code Section 45-9-85 (Payment of indemnification for death or disability) due to total permanent disability, organic brain damage, or death occurring in the line of duty.

23. For a firefighter, payments received pursuant to O.C.G.A. 25-3- 23(b)(2) (certain insurance benefits related to cancer) to the extent such amounts are included in the taxpayer's federal adjusted gross income and are not otherwise exempt on the Georgia return.

Page 15

Schedule 1 Subtractions (continued)

24. For a firefighter, an amount equal to 100% of any premium paid by the firefighter during the taxable year for coverage pursuant to O.C.G.A. 25-3-23(b)(2) (premiums paid to continue coverage by a firefighter that departs employment) to the extent such deduction has not been included in the taxpayer's federal adjusted gross income and is not otherwise deductible on the Georgia return.

25. Income received by a surviving family member that is based on the service record of a deceased veteran without regard to the age of the surviving family member.

26. For taxable years beginning on or after January 1, 2019, and ending on or before December 31, 2023, a subtraction is allowed for certain disaster relief payments. The payments that qualify are those that are received from a federal disaster relief or assistance grant program administered by Georgia or its instrumentalities or the United States Department of Agriculture but only if the federal grant program was established specifically to address agricultural losses suffered due to Hurricane Michael during the 2018 calendar year. Also, the subtraction is only allowed to the extent the income is included in federal adjusted gross income. Finally, any amounts that came from a pass-through entity are also eligible.

27. A Charitable Contributions Deduction is allowed for taxpayers who entered an amount on Form 1040 or 1040-SR, Line 12b. Please enter that amount (up to $300 or $600 married filing jointly) on the Form 500, Schedule 1, Line 12 with the description “Charitable Ded”.

Note regarding ABLE PROGRAMS - NO DEDUCTION is allowed as a subtraction item for any contribution made pursuant to the Georgia ABLE Program or any other state ABLE programs.

RETIREMENT INCOME EXCLUSION

Social security and railroad retirement paid by the Railroad Retirement Board, exempt interest, or other income that is not taxable to Georgia should not be included in the retirement income exclusion calculation. Income or losses should be allocated to the person who owns the item. If any item is held jointly, the income or loss should be allocated to each taxpayer at 50%.

Part-year residents and nonresidents must prorate the retirement income exclusion. The earned income portion and the un- earned income portion must be separately prorated. The earned income portion shall be prorated using the ratio of Georgia source earned income to total earned income computed as if the taxpayer were a resident of Georgia for the entire year. The unearned portion shall be prorated using the ratio of Georgia source unearned retirement income to total unearned retirement income computed as if the taxpayer were a resident of Georgia for the entire year.

*Retirement income does not include income received directly or indirectly from lotteries, gambling, illegal sources or similar income.

** Rental, Royalty or Partnership income that is subject to FICA tax or Self employment tax should be included on line 2 not line 13. Trade or business income from an S Corp in which the taxpayer or their spouse materially participated should be included on line 2 not line 13.

+ Note: For Lines 7a and 7b of Schedule 1 (Date of Birth and Date of Disability), the Retirement Exclusion can only be used if you meet the age or disability requirements. Both dates should not be entered. Only enter the date for which option you are using for the retirement exclusion.

Part-year/Nonresident Retirement Exclusion Example

Schedule 3: Column A Column B Column C

Ln 1 Wages 68,300 45,800 22,500

Ln 2 Interest and Dividends 82,500 82,500 0

Ln 3 Business (income or loss) 0 0 0

Ln 4 Other (income or loss) 325,150 100,000 225,150

Ln 5 Total (Total Lines 1 thru 4) 475,950 228,300 247,650

Ln 6 Total Adjustments from Form 1040 -12,000 -12,000 0

Ln 7 Sch 1 Retirement Exclusion (from step 2 below) _-65,000__-29,992 _-35,008

Ln 8 GA AGI 398,950 186,308 212,642

Step 1 Determine the Everywhere and Georgia Parts of Retirement Exclusion Step 2 Determine the Part-year/Nonresident Retirement Exclusion Allowed

Everywhere Georgia |Earned Portion

Ln 1 Wages 68,300 22,500 |Earned Income Ratio Georgia 22,500

Ln 2 Other Earned Income Everywhere 68,300 0.3294

Ln 3 Total Earned Income (Use in step 2) 68,300 22,50 |Max Earned Income 4,000

Ln 4 Max Earned Income 4,000 Georgia Earned Income Portion ——__1318

Ln 5 Smaller of Ln 3 or 4 4,000

Ln 6 Interest 82,500 QO |Unearned Portion

Ln 7 Dividend 0 0 |Total Max Exclusion 65,000

Ln 8 Alimony Portion Used on Earned Income 4,000

Ln 9 Capital Gains 30,450 30,450 |Remaining Allowed on Unearned 61,000

Ln 10 Other Income 75,150 0

Ln 11 Taxable IRA Unearned Income Ratio Georgia 225,150

Ln 12 Taxable Pensions 24,850 0 Everywhere 407,650 0.5523

Ln 13 Rent, Royalty, etc. 194,700 194,700

Ln 14 Unearned Income - Total Line 6 to 13) (Use in step 2) 407,650 225,150 |Georgia Unearned Income Portion 33,690 Total Retirement Exclusion Allowed from GA Income 35,008

Page 16

FORM 500 SCHEDULES 2 AND 3 INSTRUCTIONS

Schedule 2: Credit Usage and Carryover (Series 100) Return must be electronically filled.

1. Georgia tax credits (Series 100) must be claimed on Schedule 2. Refundable credits are claimed on schedule 2B. Currently only the Timber Tax credit is refundable but is not refundable if it was purchased. For a list of tax credit codes (series 100) see page 21. Please see the Tax Credit Summaries on the Department's website (dor.ga.gov/tax- creditsummaries) regarding Line 10 credits that can be sold. Note: Series 200 tax credit codes are claimed on IND-CR. 2. If claiming credit code 125 (QEE) enter your SSN and not the FEIN of the SSO.

3. Areturn is required to be electronically filed if the return allocates, claims, utilizes, or includes in any manner a series 100 credit (see page 21).

4. Total Schedule 2 credits used for this tax year, and enter the total on Line 20 of Form 500 or 500X.

5. The taxpayer must indicate which credits are being used. The total amount used from all Schedule 2s, the IND-CR, and from the other state(s) tax credit, and from the low income credit cannot exceed the tax liability listed on Line 16 of Form 500 or 500X.

6. If a credit is eligible for carryover to this tax year, complete the schedule even if the credit is not used in this tax year.

7. If the credit originated with more than one person or com- pany, enter separate information for each.

8. Credit certificate numbers are issued by the Department of Revenue for preapproved credits. If applicable, enter the Department of Revenue credit certificate number where indicated.

9. See the relevant forms, statutes, and regulations to deter- mine how the credit is allocated to the owners, to determine when carryovers expire, and to see if the credit is limited to a certain percentage of tax.

10. Before the Georgia tax credit carryovers are applied to the next tax year, the amount must be reduced by any amounts elected to be applied to withholding in the current tax year (for businesses only) and by any carryovers that have expired. 11. For the credit generated this year, list the Company/ Individual Name, FEIN/SSN, and Credit Certificate number, if applicable.Purchased credits should also be included. If the credit originated with this taxpayer, enter this taxpayer's name and SSN.

12. Disregarded Single Member LLC Credit Instructions. If the taxpayer owns a disregarded single member LLC, the single member LLC should be disregarded for filing purposes. All credits should be claimed on the owner’s return. All tax credit forms should be filed in the name of the single member LLC but included with the owner’s return. This is necessary so that the returns can be processed and the credits flow to the proper taxpayer.

Note: Credit certificate numbers are issued by the Depart- ment for preapproved credits. Once a credit is pre-approved, an Official letter will be issued by the Department which will contain the certificate number to the generator of the credit. If the credit is allowed to be transferred, a new certificate number will be issued from the Department to the recipient of the transferred credit. If you do not have a certificate number this field should be left blank.

Page 17

Schedule 3: Part Year and Nonresidents Note: Include copies of applicable returns and schedules with your Georgia return. LINES 1 - 4, Column A: List your income as if you were a Georgia resident. LINES 1 - 4, Column B: List your income not taxable to Georgia. LINES 1 - 4, Column C: List your Georgia taxable income. LINE 5, Columns A, B, and C: Enter the total of Lines 1- 4 in Columns A, B, and C respectively. LINES 6 - 7, Column A: List adjustments from your federal return on Line 6; list adjustments allowed by Georgia law on Line 7. See the Line 9 instructions on pages 14-16 for adjustments. LINES 6 - 7, Column B: List adjustments that do not apply to Georgia residency or do not apply because of taxable income earned as a nonresident. LINES 6 - 7, Column C: List adjustments from the Federal return that apply to Georgia on Line 6; list Georgia adjustments on Line 7. See the Line 9 instructions on pages 14-16 for adjustments. LINES 8, Columns A, B, and C: Subtract Line 6 from Line 5 in each column; and add or subtract Line 7 from Line 5 in each column. Enter the total for each column on Line 8 A, B, and C respectively. LINE 9: Divide Line 8, Column C by Line 8, Column A to calculate the ratio of Georgia income to total income. The percentage on Schedule 3, Line 9 is zero if Georgia adjusted gross income (AGI) is zero or negative. If the adjusted Federal AGI is zero or negative, the Line 9 percentage is 100%. The percentage is also considered to be 100% if both adjusted Federal and Georgia AGI are zero or negative. In this case, the taxpayer is entitled to the full exemption amount and deductions. LINE 10a and 10b: If itemizing, enter the amount from Federal Schedule A reduced by income taxes paid to other states and expense for the production of non-Georgia income. Include a copy of Federal Schedule A with your Georgia income tax return. If using the standard deduction, enter the amount for your filing status as indicated below. ™ Single/Head of Household/Qualifying Widow(er).. @ Married Filing Joint... $6,000 — Married Filing Separate... ..-$3,000 @ Additional Deduction for Blind and/or 65 or older: $1,300 LINES 11a: Multiply Form 500, Line 6c by $2,700 for filing status A or D or multiply by $3,700 for filing status B or C. LINES 11b: Multiply Form 500, Line 7a by $3,000 and enter the total. LINE 12: Add Lines 10a, 10b, 11a, and 11b. LINE 13: Multiply Line 12 by the ratio on Line 9. LINE 14: Subtract Line 13 from Line 8, Column C. This is your Georgia taxable income. Enter here and on Form 500 Line 15a. Fill in Line 15b if applicable and Line 15c. Use the income tax table or the rate schedule in this booklet to determine your tax and enter on Form 500, Line 16. Follow the instructions beginning on page 12 to complete Lines 16 through 42a of Form 500.

...-$4,600

|

Georgia FormD00 (Rev. 08/02/21)

Schedule 3 Part-Year Nonresident

2021

EXAMPLE FOR COMPLETING SCHEDULE 3 |

YOUR SOCIAL SECURITY NUMBER

Basis for Example: A husband and wife are both part-year residents of Georgia who file a joint return. Their Federal adjusted gross income is $52,000 consisting of $48,000 in salary and $4,000 of interest. They have one child and adjustments to income totali April 1. Their Schedule 3 would be completed as follows:

$2,500. They became Georgia residents on

987 65 4321

DO NOT USE LINES 9 THRU 14 OF PAGES 2AND 3 FORM 500 or 500X

SCHEDULE 3 COMPUTATION OF GEORGIA TAXABLE INCOME FOR ONLY PART-YEAR RESIDENTS AND NONRESIDENTS. Income earned in another state as a Georgia resident is taxable but other state(s) tax credit may apply. See IT-511 Tax Booklet.

FEDERAL INCOME AFTER GEORGIA ADJUSTMENT (COLUMN A)

1. WAGES, SALARIES, TIPS, etc

48 000

2. INTEREST AND DIVIDENDS 4 00 0 3. BUSINESS INCOME OR (LOSS)

4, OTHER INCOME OR (LOSS)

5. TOTAL INCOME: TOTAL LINES 1 THRU 4

52 00 0 6. TOTAL ADJUSTMENTS FROM FORM 1040 2,000

7. TOTAL ADJUSTMENTS FROM FORM 500, SCHEDULE 1

- 50 0

8. ADJUSTED GROSS INCOME: LINE 5 PLUS OR MINUS LINES 6 AND 7

49 50 0

INCOME NOT TAXABLE TO GEORGIA (COLUMN B)

WAGES, SALARIES, TIPS, etc 11 45 3

INTEREST AND DIVIDENDS 95 4

BUSINESS INCOME OR (LOSS)

. OTHER INCOME OR (LOSS)

TOTAL INCOME: TOTAL LINES 1 THRU 4 12 40 7

|. TOTAL ADJUSTMENTS FROM FORM 1040

2 00 0

. TOTAL ADJUSTMENTS FROM FORM 500,

SCHEDULE 1

ADJUSTED GROSS INCOME:

, LINE 5 PLUS OR MINUS LINES 6 AND 7

10 40 °=7

9. RATIO: Divide Line 8, Column C by Line 8, Column A. Enter percentage..........

10a. Itemized

10b. Additional Standard Deduction Self: 65 or over? Blind?

Spouse: 65 or over?

or Standard Deduction X (See IT-511 Tax Booklet).............205

Blind? Total x 1,300=

11. Personal Exemption from Form 500 (See IT-511 Tax Booklet)

11a. Enter the number on Line 6c. from Form 500 or 500X

2 multiply by $2,700 for

filing status A or D or multiply by $3,700 for filing status B or C 11b. Enter the number on Line 7a. from Form 500 or 500X 4 multiply by $3,000...

12. Total Deductions and Exemptions:

Add Lines 10a, 10b, 11a, and 11b.........

13. Multiply Line 12 by Ratio on Line 9 and enter result... ee eeeeeeeeeeeeeeeeeeee 14. Income before GA NOL: Subtract Line 13 from Line 8, Column C

Enter here and on Line 15a, Page 3 of Form 500 or Form 500X...........ceeeeeeee

Page 18

10a.

10b.

11a.

11b.

12.

GEORGIA INCOME (COLUMN C)

WAGES, SALARIES, TIPS, etc

36 54 7

INTEREST AND DIVIDENDS 3. 04 6

BUSINESS INCOME OR (LOSS)

. OTHER INCOME OR (LOSS)

TOTAL INCOME: TOTAL LINES 1 THRU 4

39 59 3

. TOTAL ADJUSTMENTS FROM FORM 1040

. TOTAL ADJUSTMENTS FROM FORM 500,

SCHEDULE 1 - 5 00

ADJUSTED GROSS INCOME: LINE 5 PLUS OR MINUS LINES 6 AND 7

39 09 3 7 8 Q9 8 > %Not to exceed 100% 6 00 0 7.40 #0 3.00 0 16 40 0 12 95 3 26 14 O

WORKSHEET FOR OTHER STATE(S) TAX CREDIT

Georgia allows a credit for tax paid to another state on income taxable to Georgia and the other state. Use these worksheets to compute the other state(s) tax credit for full-year and part-year residents. Do not file these worksheets with your return. Keep them for your records.

Enter the Total Tax Credit on Form 500 line 18. Include a copy of tax return(s) filed with other state(s). The credit is for

state (including Washington DC) and U.S. local income tax only. The tax must have been imposed on net income. No other income taxes such as foreign local, foreign city, foreign province, foreign country, U.S. Possession, etc., qualify for this credit.

FULL-YEAR RESIDENTS

1. Other state(s) adjusted gross income $ 2. Georgia adjusted gross income (Line 10, Form 500) $ 3. Ratio: Line 1 divided by Line 2 % 4. Georgia standard or itemized deductions $ 5. Georgia personal exemption and credit for dependents from

Form 500, Line 14c $ 6. Total of Line 4 and Line 5 $ 7. Line 6 multiplied by ratio on Line 3 $ 8. Income for computation of credit (Line 1 less Line 7) $ 9. Tax at Georgia rates (use tax table or rate schedule in this booklet) $ 10. Tax shown on return(s) filed with other state(s)* $ 11. Total Tax Credit (Lesser of Line 9 or Line 10) to be entered on Line

18 of Form 500 $ PART-YEAR RESIDENTS 1. Income earned in another state(s) while a Georgia resident $ 2. Georgia adjusted gross income (Line 8, Column C of

Form 500, Schedule 3) $ 3. Ratio: Line 1 divided by Line 2 % 4. Georgia standard or itemized deductions and Georgia personal

exemption and credit for dependents after applying the ratio

on Schedule 3 (Line 13, Schedule 3, Form 500) $ 5. Line 4 multiplied by ratio on Line 3 $ 6. Income for computation of credit (Line 1 less Line 5) $ 7. Tax at Georgia rates (use tax table or rate schedule in this booklet) $ 8. Tax shown on return(s) filed with other state(s) for income taxed by Georgia* $ 9. Total Tax Credit (Lesser of Line 7 or Line 8) to be entered on Line 18 of Form 500 $

*The amount entered must be reduced by credits that have been allowed by the other states.

Page 19

LOW INCOME CREDIT WORKSHEET

All claims for the low income credit, including claims on amended returns, must be filed on or before the end of the 12th month following the close of the tax year for which the credit may be claimed.

1. Enter the amount from Form 500, Line 8 or Form 500EZ, Line 1..0..........ccccccccccccsceessceceseeccssceesseeeeseceesseeseeeeaeee $.

2. Enter the number of exemptions. Exemptions are self, spouse and natural or legally adopted children..........

3. Enter 1 if you or your spouse is 65 or older; enter 2 if you and your spouse are 65 or Oldef..........0 cee

4. Add Lines 2 and 3; enter on line 17a of Form 500, or if filing the Form 500EZ, Line 5a... eee

5. Find the credit that corresponds to your income in the table below and enter on line 17b of Form 500,

or if filing the Form SOOEZ, Line 5b... cece ce ceeeeeeeceeeceseseesseceeceseesesseseceseesseseseeseseasesseceseeseeseenee $

6. Multiply Line 4 by Line 5; enter the total on line 17c of Form 500; or if filing the Form 500EZ, Line 5c............. $ Credit Table: Federal Adjusted Gross Income Credit Under $6,000 $26 $6,000 but not more than $7,999 $20 $8,000 but not more than $9,999 $14 $10,000 but not more than $14,999 $8 $15,000 but not more than $19,999 $5

SCHEDULE FOR ESTIMATING GEORGIA INCOME TAXES

(Figures may be rounded off.) Please see the Form 500ES which includes important information regarding how to file and pay estimated tax. 1. Federal Adjusted gross income expected during the current year $

2. Additions to income $ (See instructions on page 14)

3. Balance $

4. Social Security $

(See subtraction instructions on page 14)

5. Railroad Retirement $ (See subtraction instructions on page 14)

6. Applicable Retirement Exclusion $

7. Other deductions $

(See instructions on pages 14-16)

8. Balance (Subtract Lines 4 - 7 from Line 3) $

9. Personal exemption and

exemption for dependents $ 10. Standard or Itemized deductions $ 11. Taxable income (Subtract Lines 9 and 10 from Line 8) $

12. Tax on amount on Line 11 (See Georgia tax rate schedule)

13. Withholding Tax and other credits $

14. Amount from prior year’s return to be credited to this year’s estimate $

15. Estimated Tax due this year (Subtract Lines 13 and 14 from Line 12) (See 500ES) $ Page 20

TAX CREDITS

The following credits from the Taxpayer or from the ownership of a S Corp, LLC, LLP, or Partnership Interest which will be reflected on the Individual’s K-1 must be listed on Form 500, Schedule 2. The entity information and credit type code must be included. Additional documentation for claiming a credit is required where indicated.

NOTE: Credit code numbers are subject to change annually. Current code numbers are listed below. See Form IND-CR for information about additional tax credits.

NOTE: A return is required to be filed electronically if the return generates, allocates, claims, utilizes, or includes in any manner a Series 100 tax credit.

Refundable credits are claimed on Schedule 2B. Currently only the Timber Tax Credit (145) is refundable but not if it was purchased.

Disregarded Single Member LLC Credit Instructions. If the taxpayer owns a disregarded single member LLC, the single member LLC should be disregarded for filing purposes. All credits should be claimed on the owner’s return. All tax credit forms should be filed in the name of the single member LLC but included with the owner’s return. This is necessary so that the returns can be processed and the credits flow to the proper taxpayer.

For additional information on the below-listed credits, please visit the Georgia Department of Revenue website at dor.georgia. gov/documents/tax-credits.

Code Name of Credit Code Name of Credit

102 - Employer’s Credit for Approved Employee Re- training

124 - Land Conservation Credit

125 - Qualified Education Expense Credit

126 - Seed-Capital Fund Credit

128 - Wood Residual Credit

129 - Qualified Health Insurance Expense Credit 130 - Quality Jobs Tax Credit

131 - Alternate Port Activity Tax Credit

132 - Qualified Investor Tax Credit

133 - Film Tax Credit for a Qualified Interactive Enter- tainment Production Company

135 - Historic Rehabilitation Tax Credit for any Other Certified Structures (not a historic home)

103 - Employer’s Jobs Tax Credit

104 - Employer’s Credit for Purchasing Child Care Property

105 - Employer’s Credit for Providing or Sponsoring Child Care for Employees

106 - Manufacturer’s Investment Tax Credit 107 - Optional Investment Tax Credit

108 - Qualified Transportation Credit (only carryover can be used)

109 - Low Income Housing Credit

111 - Business Enterprise Vehicle Credit 112 - Research Tax Credit

113 - Headquarters Tax Credit

114 - Port Activity Tax Credit

115 - Bank Tax Credit

116 - Low Emission Vehicle Credit (only carryover can be used)

136 - Qualified Rural Hospital Organization Expense Tax Credit

137 - Qualified Parolee Jobs Tax Credit

138 - Postproduction Film Tax Credit

139 - Small Postproduction Film Tax Credit 140 - Qualified Education Donation Tax Credit 141 - Musical Tax Credit

142 - Rural Zone Tax Credit

143 - Agribusiness and Rural Jobs Tax Credit

117 - Zero Emission Vehicle Credit (only carryover can be used)

118 - New Facilities Job Credit

119 - Electric Vehicle Charger Credit 144 - Post- Consumer Waste Materials Tax Credit

120 - New Manufacturing Facilities Property Credit 121 - Historic Rehabilitation Credit for Historic Homes

122 - Film Tax Credit (Use code 133 if the credit is for a Qualified Interactive Entertainment Production Com-

pany)

Page 21

145 - Timber Tax Credit 146 - Railroad Track Maintenance Tax Credit

147 - Personal Protective Equipment Manufacturer Jobs Tax Credit

148 - Life Sciences Manufacturing Job Tax Credit

EXAMPLE OF HOW TO FILL OUT A TAX CREDITS SCHEDULE FOR CREDITS THAT DO NOT REQUIRE PRE-APPROVAL

If receiving the same credit type from multiple entities, you must complete one tax credit schedule for each credit code. For the credit generated this tax year, list the Company Name and ID number if applicable. If the credit originated with this taxpayer, enter this taxpayer’s name and ID#. Only enter a certificate number if the Department has provided a letter with your unique certificate number because the credit is preapproved. Purchased credits and credits received from an allocation from a pass-through entity should also be included on this schedule. If a credit is purchased from a previous year the credit should be claimed as a previous year credit on line 2.

SCHEDULE 2 GEORGIA TAX CREDIT USAGE AND CARRYOVER See IT-511 Tax Booklet V. Credit Code eee ceeccncecenceneeneeenennesnnmensnnnneseeennnnneseeeeeteeeet 1. 103

2. Credit remaining from previous years (If from a business, do not include amounts elected to be applied to withholding)...

3. COMPANY/INDIVIDUAL NAME TAXPAYER'S NAME

CREDIT CERTIFICATE # FEIN/SSN CREDIT GENERATED THIS TAX YEAR 123-45-6789 45000 4. COMPANY/INDIVIDUAL NAME XYZ LLC CREDIT CERTIFICATE # FEIN/SSN CREDIT GENERATED THIS TAX YEAR 67-0009876 3000 5. COMPANY/INDIVIDUAL NAME ABC COMPANY CREDIT CERTIFICATE # FEIN/SSN CREDIT GENERATED THIS TAX YEAR 57-2233445 3000 6. COMPANY/INDIVIDUAL NAME CREDIT CERTIFICATE # FEIN/SSN CREDIT GENERATED THIS TAX YEAR 7. COMPANY/INDIVIDUAL NAME CREDIT CERTIFICATE # FEIN/SSN CREDIT GENERATED THIS TAX YEAR 8. COMPANY/INDIVIDUAL NAME CREDIT CERTIFICATE # FEIN/SSN CREDIT GENERATED THIS TAX YEAR 9. Total available credit for this tax year (sum of Lines 2 through 8)... 9. 51000

10. Enter the amount of the credit sold (only certain credits can be sold, see IT-511 Tax Booklet)..................-... a

11. Credit used for this tax year eee enneeeeeeeceeeeeneeeeenneneeeaneee 11. 5000

12. Potential carryover to next tax year (Line 9 less Lines 10 and 11)... . 12. 46000

Page 22

EXAMPLE OF HOW TO FILL OUT A TAX CREDITS SCHEDULE FOR CREDITS THAT REQUIRE PRE-APPROVAL

If receiving the same credit type from multiple entities, you must complete one tax credit schedule for each credit code. For the credit generated this tax year, list the Company Name and ID number if applicable. If the credit originated with this taxpayer, enter this taxpayer’s name and ID#. Only enter a certificate number if the Department has provided a letter with your unique certificate number because the credit is preapproved. Purchased credits and credits received from an allocation from a pass-through entity should also be included on this schedule. If a credit is purchased from a previous year the credit should be claimed as a previous year credit on line 2.

SCHEDULE 2 GEORGIA TAX CREDIT USAGE AND CARRYOVER See IT-511 Tax Booklet 1. 125

2. Credit remaining from previous years (If from a busi

amounts elected to be applied to withholding). 2 3. COMPANY/INDIVIDUAL NAME TAXPAYER'S NAME

CREDIT CERTIFICATE # FEIN/SSN CREDIT GENERATED THIS TAX YEAR

011223344 123-45-6789 10000 4. COMPANY/INDIVIDUAL NAME CREDIT CERTIFICATE # FEIN/SSN CREDIT GENERATED THIS TAX YEAR 5. COMPANY/INDIVIDUAL NAME CREDIT CERTIFICATE # FEIN/SSN CREDIT GENERATED THIS TAX YEAR 6. COMPANY/INDIVIDUAL NAME CREDIT CERTIFICATE # FEIN/SSN CREDIT GENERATED THIS TAX YEAR 7. COMPANY/INDIVIDUAL NAME CREDIT CERTIFICATE # FEIN/SSN CREDIT GENERATED THIS TAX YEAR 8. COMPANY/INDIVIDUAL NAME CREDIT CERTIFICATE # FEIN/SSN CREDIT GENERATED THIS TAX YEAR 9. Total available credit for this tax year (sum of Lines 2 through 8).......-....-.-..-.....- 9. 10000

10. Enter the amount of the credit sold (only e certain credits can be sold, see IT-511 Tax Booklet)...

11. Credit used for this tax year... 22... eee eee ecee eee eect eee eee eee eects 11.

12. Potential carryover to next tax year (Line 9 less Lines 10 and 11)... 12. 10000

Page 23

CHECKOFF GEORGIA

Pick an Amount & Make it Count!

Pick an amount and make it count by donating on your State Income Tax Return form to one or more of the following Checkoff Georgia charitable organizations.

Grove Deneve or Cowwoyrry Heart

GEORGIA

core

CENTER for ONCOLOGY RESEARCH & EDUCATION

SPAY AND NEUTER

GSFA

Georgia Student Finance Authority

The Georgia Wildlife Conservation Fund protects and preserves Georgia’s nongame wild- life, including bald eagles, sea turtles, and other animals that are not hunted, trapped or fished. Georgia Department of Natural Resources / 2070 U.S. Hwy 278 S.E. / Social Circle, GA 30025 / 706-557-3333 / http://georgiawildlife.com

The Georgia Fund for Children and Elderly provides programs for preschool children with spe- cial needs plus home-delivered meals and transportation for elders. DHS Division Aging Services / 404-657-5258 / http://aging.georgia.gov/georgia-fund-children-and-elderly ; DCH / Division of Public Health / MCH / Children and Youth with Special Needs / 404-657-2700 / http://dph.georgia.gov

The Georgia Cancer Research Fund supports innovative and promising research on all types of cancer. Funds often provide seed money for pilot projects to help scientists obtain data needed to win grants from national cancer organizations. Georgia Center for Oncology Research and Education / 50 Hurt Plaza, Suite 1415 /Atlanta, GA 30303 / 404-588-4083

The Georgia Land Conservation Program provides funds for land conservation to protect natural resources and increase the state’s economic competitiveness. Georgia Environmental Finance Authority / 233 Peachtree St NE, Suite 900 /Atlanta, GA 30303

The Georgia National Guard Foundation Inc. provides emergency relief assistance to the soldiers and airmen of the Georgia National Guard and other qualified members of the Georgia Depart- ment of Defense. Georgia National Guard Foundation/ 1000 Halsey Ave. BLDG. 447/ Marietta, GA 30060 / 678-569-5704 / http://georgiaquardfamily.org/

The Dog and Cat Sterilization Fund provides financial support for the sterilization of dogs and cats, as well as education to the public about the healthy benefits of animal sterilization. DCSF / 19 Martin Luther King Jr. Drive SW/Atlanta, GA 30334 / 404-656-4914 / http://agr.qgeorgia.gov

The Saving the Cure Fund is designed to encourage the donation, collection and storage of stem cells from postnatal tissue and fluid; make such stem cells available for medical research and treatment; promote principled and ethical stem cell research; and to encourage stem cell research with immediate clinical and medical applications.

Realizing Educational Achievement Can Happen (REACH) Program provides low-income academically promising students with the academic, social, and financial support needed to graduate from high school, access college, and achieve post-secondary success. Georgia Student Finance Authority / 2082 East Exchange Place / Tucker, GA 30084 / 770-724-9248 |

https://reachga.org/

The Public Safety Memorial Grant Program administered by the Georgia Student Finance Authority, provides educational aid to children whose parents are/were public safety employees and were disabled or killed in the line of duty, Recipients attend eligible colleges and universities in Georgia. Georgia Student Finance Authority / 2082 East Exchange Place / Tucker, GA 30084 / (800) 505-4732 / www.gafutures.org

Page 24

THIS PAGE INTENTIONALLY LEFT BLANK

Page 25

2200405913

Please print your numbers like this in black or blue ink:

Georgia Form 500 (Rev. 02/09/22) a | ec |e | | yl = Individual Income Tax Return _| . oe ee | _| = Georgia Department of Revenue

2021 (Approved booklet version)

Page 4 Fiscal Year - - Beginning STATE ISSUED . YOUR DRIVER’S Fiscal Year . - LICENSE/STATE ID Ending YOUR FIRST NAME MI YOUR SOCIAL SECURITY NUMBER 1. - - LAST NAME (For Name Change See IT-511 Tax Booklet) SUFFIX SPOUSE’S FIRST NAME MI SPOUSE’S SOCIAL SECURITY NUMBER [| - - DEPARTMENT USE ONLY LAST NAME SUFFIX ADDRESS (NUMBER AND STREET or P.O. BOX) (Use 2nd address line for Apt, Suite or Building Number)L_] CHECK IF ADDRESS HAS CHANGED 2. CITY (Please insert a space if the city has multiple names) STATE ZIP CODE 3.

(COUNTRY IF FOREIGN)

Residency Status 4. Enter your Residency Status with the appropriate number

1. FULL- YEAR RESIDENT 2. PART- YEAR RESIDENT TO

3. NONRESIDENT

Omit Lines 9 thru 14 and use Form 500 Schedule 3 if you are a part-year or nonresident filer.

Filing Status 5. Enter Filing Status with appropriate letter (See IT-511 Tax Booklet).........0.0.00ccc ccc cece cee es cece ceceeeesceeseesseeeesaeeenececeaee 5.

ASingle B.Marriedfilingjoint _C. Married filing separate (Spouse's social security number must be entered above) D. Head of Household or Qualifying Widower)

6. Number of exemptions (Check appropriate box(es) and enter total in 6c.) 6a. Yourself Oo] 6b. Spouse Oo 6c. [|

7a. Number of Dependents (Enter details on Line 7b., and DO NOT include yourself or your SpOuSE)..................:.c0ccceseeeees Ta.

~ PAGES (1-5) ARE REQUIRED FOR PROCESSING

Individual Income Tax Return

Georgia Department of Revenue 2200405923

2021 page 9

7b. Dependents (If you have more than 4 dependents, attach a list of additional dependents)

YOUR SOCIAL SECURITY NUMBER

First Name, MI. Last Name

Social Security Number Relationship to You First Name, MI. Last Name

Social Security Number Relationship to You First Name, MI. Last Name

Social Security Number Relationship to You First Name, MI. Last Name

Social Security Number Relationship to You

> INCOME COMPUTATIONS

If amount on line 8, 9, 10, 13 or 15 is negative, use the minus sign (-). Example -3456.

8. Federal adjusted gross income (From Federal Form 1040)... cece eee 8.

(Do not use FEDERAL TAXABLE INCOME) If the amount on Line 8 is $40,000 or more, or your g W-2s you must include a copy of your Federal Form 1040 Pages 1, 2, and Schedule 1.

9. Adjustments from Form 500 Schedule 1 (See IT-511 Tax Booklet) ......0.c 9. 10. Georgia adjusted gross income (Net total of Line 8 and Line 9)... 10. 11. Standard Deduction (Do not use FEDERAL STANDARD DEDUCTION).............. 11a.

(See IT-511 Tax Booklet) b. Self: 65 or over? L] Blind? L] Total L] XK 1,3007 2... eeeeeeeeeeeeeeeeee 11b.

Spouse: 65 or over? O Blind?

c. Total Standard Deduction (Line 11a + Line 11b). Use EITHER Line 11c OR Line 12c (Do not write on both lines)

ross income is less than your

sseee

8

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)..........::::cesesseseeees 12a. 5 5 b. Less adjustments: (See IT-511 Tax Booklet) ...........:.:cccceeessssseseeeeeeesseseetees 12b. 5 5 c. Georgia Total Itemized Deductions. .............cccccceseseseeeeeeesesesesseeseneeseneseesens 12c. 5 5 13. Subtract either Line 11c or Line 12c from Line 10; enter balance..............:::0008 13. ) 5

| PAGES (1-5) ARE REQUIRED FOR PROCESSI

NG

Bssee

= = Georgia Form 500 Individual Income Tax Return

Georgia Department of Revenue 2200405933 YOUR SOCIAL SECURITY NUMBER

Page 3 14a. Enter the number from Line col _| Multiply by $2,700 for filing status AorD 14a. r] . 00

or multiply by $3,700 for filing status B or C 14b. Enter the number from Line raL_l Multiply by $3,000....... 14b. 5 . 00 14c. Add Lines 14a. and 14b. Enter total ............cccccceceeeeseseeeseeeeeeeeeeeeeeeeee 14c. 5 . 00 15a. Income before GA NOL (Line 13 less Line 14c or Schedule 3, Line 14)..... 15a. 5 5 . 00 15b. Georgia NOL utilized (Cannot exceed Line 15a or the amount after

applying the 80% limitation, see IT-511 Tax Booklet for more information)....15b. ) ) . 00 15c. Georgia Taxable Income (Line 15a less Line 15b).....0....ccccceeeeeseesetetees 15c. 5 5 . 00 16. Tax (Use Tax Table or Tax Rate Schedule in the IT-511 Tax Booklet) ....... 16. , 5 . 00

, 00

17. Low Income Credit 17a Wb. eee 17c. . 18. Other State(s) Tax Credit (Include a copy of the other state(s) return) ....... 18. 5 5 . 00 19. Credits used from IND-CR Summary Worksheet . 19. 5 5 . 00 20. Total Credits Used from Schedule 2 Georgia Tax Credits (must be filed 20.

electronically) 21. Total Credits Used (sum of Lines 17-20) cannot exceed Line 16.0... 21. , 5 . 00 22. Balance (Line 16 less Line 21) if zero or less than zero, enter zero .......... 22. , 5 . 00

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.

(INCOME STATEMENT A) (INCOME STATEMENT B) (INCOME STATEMENT C) 1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE: Ow2 Ole2za cap Owe Ocean [cat Ow2 Ole2a 2 cate D1009 ~[1e2rt 1 c2rp O1009 [cert OF c2-rp O1099 [J cart 1 Gz2-rP 2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL ID NUMBER (FEIN) [] ssn [_] ID NUMBER (FEIN) [_] ssn [_] ID NUMBER (FEIN) [] ssn []

3. _EMPLOYER/PAYER STATE WITHHOLDING ID 3. _EMPLOYER/PAYER STATE WITHHOLDING ID 3. _EMPLOYER/PAYER STATE WITHHOLDING ID

LILI TT I ttt | - LILI T TI ttt |

4. GAWAGES / INCOME 4. _GAWAGES / INCOME 4. _GAWAGES / INCOME

J iu . J iu . J iu . 5. _GA TAX WITHHELD 5. GA TAX WITHHELD 5. GA TAX WITHHELD

b J " 5 5 . 5 5 .

PLEASE COMPLETE INCOME STATEMENT DETAILS ON PAGE 4.

PAGES (1-5) ARE REQUIRED FOR PROCESSING

= = Georgia Form 500 Individual Income Tax Return

Georgia Department of Revenue 2200405943 YOUR SOCIAL SECURITY NUMBER Page 4 (INCOME STATEMENT D) (INCOME STATEMENT E) (INCOME STATEMENT F) 1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE: OO wz (J) c2a [] cop O wz [e624 [] c2ip Ol wz [Jc62a [ cap 0 1099 [] G2-rt [] G2-rp 1 1099 [] c2rt [] Garp 1 1099 [] car. [ carp 2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL

ID NUMBER (FEIN) SSN NUMBER (FEIN) SSN NUMBER (FEIN) SSN

3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID

- - LILI TIT tT Ty

4. GA WAGES / INCOME 4. GA WAGES / INCOME 4. GAWAGES / INCOME 00 00 bl J . bl J . bl J . 00 5. _GA TAX WITHHELD 5. GA TAX WITHHELD 5. GA TAX WITHHELD 00 00 00 I J " I J " I I " 23. Georgia Income Tax Withheld on Wages and 1099s .......... ee 23. 5 5 . 00 (Enter Tax Withheld Only and include W-2s and/or 1099s) 24. Other Georgia Income Tax Withheld..........0.000 reece 24. 5 5 . 00 (Must include G2-A, G2-FL, G2-LP and/or G2-RP) 25. Estimated Tax paid for 2021 and Form IT-560 .. 25. ) 5 . 00 26. Schedule 2B Refundable Tax Credits............:.:cccccceccsssseseetesessesstesesseeseeeee 26. (Cannot be claimed unless filed electronically)

27. Total prepayment credits (Add Lines 23, 24, 25 and 26)... 27. 5 5 . 00 28. If Line 22 exceeds Line 27, subtract Line 27 from Line 22 and enter 00 balance Cue........ceccccecccseecsceeesssceseseeesecescseeeeessecsseteassseeseceassseesiseasatersaseaees 28. ) ) = 29. If Line 27 exceeds Line 22, subtract Line 22 from Line 27 and enter 00

OVEFPAYMENE ooo. cece cee eee ce ceeeeeecee cesses ceeceeseeeeseeseeeseeseeeeseseeseeeeeeeee 29. 5 5 . . 00

30. Amount to be credited to 2022 ESTIMATED TAX ..........ssseeseseeseseseseees 30. 5 5 . 31. Georgia Wildlife Conservation Fund (No gift of less than $1.00)............. 31. 5 . 00 32. Georgia Fund for Children and Elderly (No gift of less than $1.00).. 32. 5 . 00 33. Georgia Cancer Research Fund (No gift of less than $1.00) ...........:00 33. 5 . 00 34. Georgia Land Conservation Program (No gift of less than $1.00)........... 34. 5 . 00 35. Georgia National Guard Foundation (No gift of less than $1.00)............. 35. 5 . 00 36. Dog & Cat Sterilization Fund (No gift of less than $1.00).......... eee 36. 5 . 00 37. Saving the Cure Fund (No gift of less than $1.00).......... essere 37. 5 . 00 38. Realizing Educational Achievement Can Happen (REACH) Program .....s00 38. 5 . 00

(No gift of less than $1.00)

| PAGES (1-5) ARE REQUIRED FOR PROCESSING |

a Georgia Form 500

Individual Income Tax Return Georgia Department of Revenue

2021 Page 5

39. Public Safety Memorial Grant (No gift of less than $1.00).

40. Form 500 UET (Estimated tax penalty) | 500 UET exception attached

2200405953

41. (If you owe) Add Lines 28, 31 thru 40

MAKE CHECK PAYABLE TO GEORGIA DEPARTMENT OF REVENUE..

Amount Due Mail To:

GEORGIA DEPARTMENT OF REVENUE

PROCESSING CENTER, PO BOX 740399 ATLANTA, GA 30374-0399

39.

40.

a1.

YOUR SOCIAL SECURITY NUMBER

42. (If you are due a refund) Subtract the sum of Lines 30 thru 40 from Line 29

THIS IS YOUR REFUND..................

If you do not enter Direct Depos

42a. Direct Deposit (U.S. Accounts Only)

Type: Checking L_]

Savings oO

Routing Number

42. information or if you are a first time filer you will be issued a paper check.

Account Number

Refund Due Mail To:

GEORGIA DEPARTMENT OF REVENUE PROCESSING CENTER, PO BOX 740380 ATLANTA, GA 30374-0380

INCLUDE ALL ITEMS IN ENVELOPE, DO NOT STAPLE YOUR CHECK, W-2s, OTHER WITHHOLDING DOCUMENTS, OR TAX RETURN. \/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.

Taxpayer's Signature

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[1 (Check box if deceased)

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ture Date

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my account(s).

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By providing my e-mail address | am authorizing the Georgia Department of Revenue to electronically notify me at the below e-mail address regarding any updates to

O

| authorize DOR to discuss this return with the named preparer.

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’s FEIN

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PAGES (1-5) ARE REQUIRED FOR PROCESSING |

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| Georgia Form)00

Schedule 1 2207205 Adjustments to Income

2021 (Approved booklet version)

(Rev. 08/02/21) ll | ll | | | | | ll

913

Schedule 1 Page 1

YOUR SOCIAL SECURITY NUMBER

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 .............:cccseceeeeeeees 1. 5 2. Lump Sum Distributions 0... eee eeeseeseesneeseeesnesseesnteseeesesseesnneseeesneeaneenee 2. 5 3. RESCIVED......sceccsseescsseesesssessssnesssssesesssessssnesessneeessnecssseseesueecsssasesssesessnsessneeessneetssesersee 3. 4. Net operating loss carryover deducted on Federal return... cesses 4. 5 5. Other (Specify) 5. 5 6. Total Additions (Enter sum of Lines 1-5 here)...0..0.0.0 cece cece eects 6. 5 SUBTRACTION from INCOME 7. Retirement Income Exclusion (See IT-511 Tax Booklet) Complete Schedule 1, page 2 if claiming Retirement Income Exclusion. a. Self: Date of Birth Date of Disability: Type of Disability: : : - - Ta. 5 b. Spouse: Date of Birth Date of Disability: Type of Disability: - - : : 7b. ) 8. Social Security Benefits (Taxable portion from Federal return)..........0..08 8. ) 9. Path2College 529 Plan ..........cccececsescseseeseeeseessseesesessesssseeeescsessesseeeessesesees 9. 5 10. Interest on United States Obligations (See IT-511 Tax Booklet ) 10. 5 11. RESOrVEd 2... ccesescsesceeeeeseesscaeeseecesasssseseesessisseeeseessesesiteterentasetiteaees 11. 12. Other Adjustments (Specify) Adjustment Amount 5 Adjustment Amount 5 Adjustment Amount 5 Adjustment Amount 5 Total ooo eeseeeceeeneeeeeeeees 12. 5 13. Total Subtractions (Enter sum of Lines 7-12 here) .......0c eee eects 13. ) 14. Net Adjustments (Line 6 less Line 13). Enter Net Total here and on Line 9 of Page 2 (+ or -) of Form 500 or 500X ou... eee cece eee 14. 5

8

|_| Schedule1 Hi Georgia FormD00 Page 2 (Rev. 08/02/21)

Schedule 1 2207205923 YOUR SOCIAL SECURITY NUMBER Adjustments to Income - -

2021 (Approved booklet version)

[ SCHEDULE 1 RETIREMENT INCOME EXCLUSION See IT-511 Tax Booklet | (TAXPAYER) (SPOUSE) 1. Salary and WaQeS.......ceccceeeneceseeeeeee ) 00 ) . 00 b . b 2. Other Eamed Income (LOSSES).........-:ceeee 5 ) . 00 5 ) . 00 3. Total Eamed Income... 5 ; . 00 ) 5 . 00 4. Maximum Eamed Income........c0ccceeeeeeee 4 olo! ol oo 4 o!o} 0! 00 3 I . 3 I . 5. Smaller of Line 3 or 4; if zero or less, enter 00 00 ZOTO voeecceceesseessteeseeseeesieeseesesseestesneesness ) ) . 5 ) . 00 00 6. Interest INCOME... scene 5 ) . 5 ) . 7. Dividend INCOME .......cseececeseeseetesteeeenee ) 5 . 00 5 ) . 00 i 00 8. ALIMONY... cesses ceeee ects neseeseeeeneeneenees ) 5 . 00 ) 5 . 9. Capital Gains (LOSSES)... cece 5 5 . 00 ) 5 . 00 10. Other Income (LOSSES)........ceceeeeeeeeeees 5 5 . 00 ) 5 . 00 (See IT-511 Tax Booklet) 11. Taxable IRA Distributions.........0.cccecee 5 ) . 00 5 ) . 00 12. Taxable Pensions ..........ceceeceeeneeeeee 5 5 . 00 ) 5 . 00 13. Rental, Royalty, Partnership, S Corp, etc. Income (Losses).....(See IT-511 Tax Booklet) ; ; _ 00 ; ; _ 00 14. TotalofLines6 through 13; if zero or less, QMLEL ZOLO oe eeecseceeseseeseeeeseeeeseeseseeseeetseeee 00 00 ’ ’ . ) ) . 15. AddLines5 and 14 wu... 5 5 . 00 5 5 . 00 16. Maximum Allowable Exclusion* . . 5 ) . 00 ) 5 . 00 17. Smaller of Lines 15 and 16; enterhere and on Form 500, Schedule 1, Lines 7a. & b........ ; ; _ 00 ; ; _ 00

*If age 62-64 or less than age 62 and permanently disabled enter $35,000, or if age 65 or older enter $65,000.

| Schedule3 Hl Georgia FormD00 Page 1 (Rev. 08/02/21)

Schedule 3 2207405913 YOUR SOCIAL SECURITY NUMBER Part-Year Nonresident

20211 (Arproved bookie version DO NOT USE LINES 9 THRU 14 OF PAGES 2 AND 3FORM 500 or 500X

SCHEDULE 3 COMPUTATION OF GEORGIA TAXABLE INCOME FOR ONLY PART-YEAR RESIDENTS AND NONRESIDENTS. Income earned in another state as a Georgia resident is taxable but other state(s) tax credit may apply. See IT-511 Tax Booklet.

FEDERAL INCOME AFTER GEORGIA ADJUSTMENT INCOME NOT TAXABLE TO GEORGIA GEORGIA INCOME (COLUMN A) (COLUMN B) (COLUMN C) 1. WAGES, SALARIES, TIPS, etc 1,__ WAGES, SALARIES, TIPS, etc 1.__WAGES, SALARIES, TIPS, etc u 7 0 I , 0 I I 0 2. INTEREST AND DIVIDENDS 2. INTEREST AND DIVIDENDS 2. INTEREST AND DIVIDENDS , ; . 00 ; ; . 00 ; ; _ 00 3. BUSINESS INCOME OR (LOSS) 3. BUSINESS INCOME OR (LOSS) 3. BUSINESS INCOME OR (LOSS) 7 7 . 00 , Hy . 00 5 5 . 00 4. OTHER INCOME OR (LOSS) 4. OTHERINCOME OR (LOSS) 4. OTHER INCOME OR (LOSS) J I . 00 , Hy . 00 , Hy . 00 5. TOTALINCOME: TOTAL LINES 1 THRU 4 5. TOTAL INCOME: TOTAL LINES 1 THRU 4 5.__ TOTAL INCOME: TOTAL LINES 1 THRU 4 J , - 0 I , . 00 5 5 . 00 6. TOTAL ADJUSTMENTS FROM FORM 1040 6. TOTAL ADJUSTMENTS FROM FORM 1040 6._ TOTAL ADJUSTMENTS FROM FORM 1040 3 3 . 3 3 . 3 t . 7. TOTAL ADJUSTMENTS FROM FORM 500, 7. TOTAL ADJUSTMENTS FROM FORM 500, 7. TOTAL ADJUSTMENTS FROM FORM 500, SCHEDULE 1 SCHEDULE 1 SCHEDULE 1 3 t " 00 3 t . 00 3 3 . 00 8. ADJUSTED GROSS INCOME: 8. ADJUSTED GROSS INCOME: 8. ADJUSTED GROSS INCOME: LINE 5 PLUS OR MINUS LINES 6 AND 7 LINE 5 PLUS OR MINUS LINES 6AND 7 LINE 5 PLUS OR MINUS LINES 6 AND 7 00 0 0 3 t . 3 3 b) 3 woe + + % Not t d 100% 9. RATIO: Divide Line 8, Column C by Line 8, Column A enter percentage ....... 9. . of toexcee 10a. Itemized Cor Standard Deduction oO (See IT-511 Tax Booklet)....cccccssssssssesesssessssnesssesnsseenseee 10a. 5 5 . 00

10b. Additional Standard Deduction [| Self: 65 or over? L_] Biina?|_] Spouse: 65 or over? oO tind otal X 1,300= 10b. . 00

11. Personal Exemptions from Form 500 or Form 500X (See IT-511 Tax Booklet)

11a. Enter the number on Line 6c from Form 500 or Form 500X L] multiply by $2,700 for

filing status A or D or multiply by $3,700 for filing status B or C. 11a. 5 5 . 00 11b. Enter the number on Line 7a from Form 500 or Form sooxl_| multiply by $3,000 .. 11b. . 00 b b 12. Total Deductions and Exemptions: Add Lines 10a, 10b, 11a, and 11b............ 12. 5 5 . 00 13. Multiply Line 12 by Ratio on Line 9 and enter result... cece eeeeeeeeeeeeeeees 13. 5 5 . 00 14. Income before GA NOL: Subtract Line 13 from Line 8, Column C 00 Enter here and on Line 15a, Page 3 of Form 500 or Form 500X..........:cceeee 14. 5 5 .

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a P a rorm IND-CR 201 age 4 State of Georgia Individual Credit Form

Georgia Department of Revenue 2208005915 2021 (Rev. 08/02/21) (Approved booklet version)

— Include with Form 500 or 500X, if this schedule is applicable.— YOUR SOCIAL SECURITY NUMBER

> SCHEDULE 201 Disabled Person Home Purchase or Retrofit Credit - Tax Credit 201

Disabled Person Home Purchase or Retrofit Credit - Tax Credit 201 O.C.G.A.§ 48-7-29.1 provides a disabled person credit equal to the lesser of $500 per residence or the taxpayer’s income tax liability for the purchase of a new single-family home that contains all of the accessibility features listed below. It also provides a credit equal to the lesser of the cost or $125 to retrofit an existing single-family home with one or more of these features. The disabled person must be the taxpayer or the taxpayer's spouse if a joint return is filed. Qualified features are:

@ One no-step entrance allowing access into the residence.

@ Interior passage doors providing at least a 32-inch-wide opening.

@ Reinforcements in bathroom walls allowing installation of grab bars around the toilet, tub, and shower, where such facilities are provided.

@ Light switches and outlets placed in accessible locations.

To qualify for this credit, the disabled person must be permanently disabled and have been issued a permanent parking permit by the Department of Revenue or have been issued a special permanent parking permit by the Department of Revenue.

This credit can be carried forward 3 years. For more information, see Regulation 560-7-8-.44.

1. Credit remaining from previoUS YeaPs.......... cece eeeereeeeeeeeeeneeeeeeneeeteeeseeeeeetereseetneeteeees 1. Los . 00 2. Purchase of a home that contains all four accessibility features OR total of accessibility

features added to retrofit a home (up to $125 per feature) cannot exceed $500 [—]

PCr FESIDONCE... eee cece eee ccc ee cee eee ceeceeeeeceeecsecaeeeececesseceeseesessesseseeeesesiessesieeeseseeseesieeaeeaeey 2. Loy . 00 3. Credit used this tax year (enter here and include on IND-CR Summary Worksheet Line 1).3. LJ, . 00 4. Potential carryover to next tax year (Line 1 plus Line 2 less Line 3) «0.0... eee 4. Loy . 00

| rom IND-CR 202 State of Georgia Individual Credit Form

Georgia Department of Revenue 2208105915

Page |

2021 (Rev. 08/02/21) (Approved booklet version)

— Include with Form 500 or 500X, if this schedule is applicable. — yoursociat security NUMBER

> SCHEDULE 202 Child and Dependent Care Expense Credit - Tax Credit 202

Child and Dependent Care Expense Credit - Tax Credit 202

0.C.GA. § 48-7-29.10 provides taxpayers with a credit for qualified child & dependent care expenses. The credit is a percentage of the credit claimed and allowed under Internal Revenue Code § 21 and claimed by the taxpayer on the taxpayer’s Federal

income tax return. This credit cannot be carried forward. The credit is computed as follows:

1. Amount of child & dependent care expense credit claimed on Federal Form 1040.

2. Georgia allowable rate

3. Allowable Child & Dependent Care Expense Credit (Line 1 x .30)

4.Credit used this tax year (enter here and include on IND-CR Summary Worksheet

1.

| P | rom IND-CR 203 age 4 State of Georgia Individual Credit Form

Georgia Department of Revenue 2208205915 2021 (Rev. 08/02/21) (Approved booklet version)

— Include with Form 500 or 500X, if this schedule is applicable. — —_ Yoursociat security NUMBER

> SCHEDULE 203 Georgia National Guard/Air National Guard Credit - Tax Credit 203

Georgia National Guard/Air National Guard Credit - Tax Credit 203

0.C.GA. § 48-7-29.9 provides a tax credit for Georgia residents who are members of the National Guard or Air National Guard

and are on active duty full time in the United States Armed Forces, or active duty training in the United States Armed Forces for a period of more than 90 consecutive days. The credit shall be claimed and allowed in the year in which the majority of such

days are served. In the event an equal number of consecutive days are served in two calendar years, then the exclusion shall be claimed and allowed in the year in which the ninetieth day occurs. The credit shall apply with respect to each taxable year in

which such member serves for such qualifying period of time. The credit cannot exceed the amount expended for qualified life insurance premiums nor the taxpayer’s income tax liability. Qualified life insurance premiums are the premiums paid for

insurance coverage through the service member’s Group Life Insurance Program administered by the United States Department of Veterans Affairs. Any unused tax credit is allowed to be carried forward to the taxpayer’s succeeding year’s tax liability.

1. Credit remaining from preVioUS YeaIS.............cccec eee eee eeeeeeeteeeeeeeeeeee 1. 5 . 00

2. Enter amount of qualified life insurance PreMiUMS ..........eceeeee Qe 5 . 00

3.Credit used this tax year (enter here and include on IND-CR Summary Worksheet Line 3)......ccccscsscssescssessesssessssssesreasssseseaseseateatssseseessaeseeseaeeseases 3. 00

4. Carryover to next tax year (Line 1 plus Line 2 less Line 3)... 4. 5 5 . 00

| P | rorm IND-CR 204 age 4 State of Georgia Individual Credit Form

Georgia Department of Revenue 2208305915 2021 (Rev. 08/02/21) (Approved booklet version)

— Include with Form 500 or 500X, if this schedule is applicable.— —_ yoursociat security NUMBER

> SCHEDULE 204 Qualified Caregiving Expense Credit - Tax Credit 204

Qualified Caregiving Expense Credit - Tax Credit 204

0.C.GA. § 48-7-29.2 provides a qualified caregiving expense credit equal to 10 percent of the cost of qualified caregiving expenses for a qualifying family member. The credit cannot exceed $150. Qualified services include Home health agency services, personal care services, personal care attendant services, homemaker services, adult day care, respite care, or health care equipment and other supplies which have been determined by a physician to be medically necessary. Services must be obtained from an organization or individual not related to the taxpayer or the qualifying family member.

The qualifying family member must be at least age 62 or been determined disabled by the Social Security Administration. A qualifying family member includes the taxpayer or an individual who is related to the taxpayer by blood, marriage or adoption. Qualified caregiving expenses do not include expenses that were subtracted to arrive at Georgia net taxable income or for which amounts were excluded from Georgia net taxable income. There is no carryover or carry-back available. The credit cannot exceed the taxpayer’s income tax liability. For more information, see Regulation 560-7-8-.43.

Qualifying Family Member Name:

Name:

SS# - - Relationship

Age, if 62 or over If disabled, date of disability - -

Additional Qualifying Family Member Name, if applicable:

Name:

SS# - - Relationship

Age, if 62 or over If disabled, date of disability - -

1. Qualified Caregiving ExPeNSeS............ cece cece cee eeeceeeeeeeeceseteessesseseeseaeeneeaeees 1 5 . 00

0

2. Percentage limitation... cece cece cee ee neces eceeeecneeeeesseeesneeseeesneesneeeeeees 2. 10 %

3. Line 1 multiplied by Line 2.00.0... cece cece cee eee cesses eeeeseenesteeteeeeeeateee 3. 5 . 00

A. Maximum Credit... eee eeeereeeeeeeeeeeeneeeeeeeeeeeeseneeeeeeaeeeseeneeeseneneeeeennaee 4. 1 5 lol . 00 5 ; . 00 6. ; . 00

| P | rorm IND-CR 206 age 4 State of Georgia Individual Credit Form

Georgia Department of Revenue 2208505915 2021 (Rev. 08/02/21) (Approved booklet version)

— Include with Form 500 or 500X, if this schedule is applicable.— —_ Yoursociat security NUMBER

> SCHEDULE 206 Disaster Assistance Credit - Tax Credit 206 |

Disaster Assistance Credit - Tax Credit 206

0.C.G.A. § 48-7-29.4 provides for a credit for a taxpayer who receives disaster assistance during a taxable year from the Georgia Emergency Management and Homeland Security Agency or the Federal Emergency Management Agency. The amount of the credit is equal to $500 or the actual amount of the disaster assistance, whichever is less. The credit cannot exceed the taxpayer’s income tax liability. Any unused tax credit can be carried forward to the succeeding years’ tax liability but cannot be carried back to the prior years’ tax liability. The approval letter from the disaster assistance agency must be enclosed with the return.

The following types of assistance qualify:

H Grants from the Department of Human Services’ Individual and Family Grant Program.

M@ Grants from GEMA/HS and/or FEMA.

@ Loans from the Small Business Administration that are due to disasters declared by the President or Governor.

Disaster assistance agency

1. Credit remaining from preVioUS YEaMS......... eee eee eee tee eeeeeteeeeeeeeeeneeeneeeees 1. ’ . 00 2. Date assistance WaS reCeiVEd.........c cece cece eee ce eeeeeeceeeceeeeeseeteeesetennnees 2. - -

3. Amount of the disaster assistance reCeiVed............cccceeceeeeeeeeeseeeeeeees 3. , - 00 4. Maximum credit... eee ce reece tee eee teesee tases teeeneteeeeeeaanaes 4. 5 0 0 . 0 5. Enter the lesser of Line 3 or LINC 4.0.0.0... cece cect eee eeeeceeeecseeeeeeteeseeeeaeeeeees 5. 5 . 00 6. Credit used this tax year (enter here and include in IND-CR Summary 00

Worksheet Line 6)......... cc ceeceeeeeseeneeeeeeneeeeeeeecaeeeaeeeecaeeeaeeaeteeeteeseneteeteeeeeenaees 6. 5 .

7. Carryover to next tax year (Line 1 plus Line 5 less Line 6) 7 . 00

| Form IN D-C R 207 State of Georgia Individual Credit Form

UMMM eset

Georgia Department of Revenue 2208605915

2021 (Rev. 08/02/21) (Approved booklet version)

— Include with Form 500 or 500X, if this schedule is applicable. — YOUR SOCIAL SECURITY NUMBER

> SCHEDULE 207 Rural Physicians Credit - Tax Credit 207

Rural Physicians Credit - Tax Credit 207

0.C.GA. § 48-7-29 provides for a $5,000 tax credit for rural physicians. The tax credit may be claimed for not more than five years. There is no carryover or carry-back available. The credit cannot exceed the taxpayer’s income tax liability. In order to qualify, the physician must meet the following conditions:

1.

The physician must have started working in a rural county after July 1, 1995. If the physician worked in a rural county prior to that date, a period of at least three years must have elapsed before the physician returns to work in a rural county.

. The physician must practice and reside in a rural county. For taxable years beginning on or after January 1, 2003, a

physician qualifies for the credit if they practice in a rural county and reside in a county contiguous to a rural county. A rural county is defined as one with 65 or fewer persons per square mile according to the United States Decennial Census of 1990 or any future such census. For taxable years beginning on or after January 1, 2012, the United States Decennial Census of 2010 is used (see regulation 560-7-8-.20 for transition rules). A listing of rural counties for purposes of the rural physicians credit may be obtained at the following web page: dor.georgia.gov

. The physician must be licensed to practice medicine in Georgia, primarily admit patients to a rural hospital, and practice in

the fields of family practice, obstetrics and gynecology, pediatrics, internal medicine, or general surgery. A rural hospital is defined as an acute-care hospital located in a rural county that contains 80 or fewer beds. For taxable years beginning on or after January 1, 2003, a rural hospital is defined as an acute-care hospital located in a rural county that contains 100 or fewer beds. For more information, see Regulation 560-7-8-.20.

Only enter the information for the taxpayer and/or the spouse if they are a rural physician.

Taxpayer Spouse 1. County of residence 1. County of residence 2. County of practice 2. County of practice 3. Type of practice 3. Type of practice 4. Date started working as a rural physician 4. Date started working as a rural physician 5. Number of hospital beds in the rural hospital 5. Number of hospital beds in the rural hospital , , 6. Rural physicians credit, enter $5,000 per rural physician......... 6. 00

7. Credit used this tax year (enter here and include on IND-CR Summary Worksheet Line 7).......0.00:cceccceeeee eee eeeeeeeeeeeeeees 7. 00

| Form IN D-C R 208 State of Georgia Individual Credit Form

Georgia Department of Revenue

2021 (Rev. 08/02/21) (Approved booklet version)

2208705915

— Include with Form 500 or 500X, if this schedule is applicable. —

Page |

YOUR SOCIAL SECURITY NUMBER

> SCHEDULE 208 Adoption of a Foster Child Credit for Adoptions Occurring in Taxable Years Beginning on or After

January 1, 2008 and before January 1, 2021

Adoption of a Foster Child Credit for Adoptions Occurring in Taxable Years Beginning on or After

January 1, 2008 and before January 1, 2021

Georgia Code Section 48-7-29.15 provides an income tax credit for the adoption of a qualified foster child. The amount of the credit is $2,000 per qualified foster child per taxable year, commencing with the year in which the adoption becomes final, and ending in the year in which the adopted child attains the age of 18. This credit applies to adoptions occurring in the taxable years beginning on or after January 1, 2008 and before January 1, 2021. Any unused credit can be carried

forward until used.

1. Credit remaining from previous YeaIS......... ee eee eeeeeeeeeeeeeeeeneeeeeeaee 1.

2. Enter $2,000 per qualified foster Child...........::::00

3. Credit used this tax year (enter here and include on IND-CR Summary

Worksheet Line 8).......0...:cceeeeeeeeeeceneeeeeeneteeeeeeeteeeeeeneees

4. Carryover to next year (Line 1 plus Line 2 less Line 3).

00

| p || rorm IND-CR 209 age 4 State of Georgia Individual Credit Form

Georgia Department of Revenue 2208805915 2021 (Rev. 08/02/21) (Approved booklet version)

— Include with Form 500 or 500X, if this schedule is applicable.— —_ Yoursociat security NUMBER

> SCHEDULE 209 Eligible Single-Family Residence Tax Credit - Tax Credit 209 |

Eligible Single-Family Residence Tax Credit - Tax Credit 209

0.C.GA. § 48-7-29.17 provides taxpayers a credit for the purchase of an eligible single-family residence located in Georgia. An eligible single-family residence is a single-family structure (including a condominium unit as defined in O.C.G.A.§ 44-3-71) that is occupied for residential purposes by a single family, that is:

a) Any residence (including a new residence, one occupied at the time of sale, or a previously occupied residence) that was for sale prior to May 11, 2009 and that remained for sale after May 11, 2009; or

b) Aresidence with respect to which a foreclosure event has taken place and which is owned by the mortgagor or the mortgagor's agent; or

c) An owner-occupied residence with respect to which the owner’s acquisition indebtedness was in default on or before March 1, 2009. Acquisition indebtedness is debt incurred in acquiring, constructing, or substantially improving a qualified residence and which is secured by such residence. Refinanced debt is acquisition debt if at least a portion of such debt refinances the principal amount of existing acquisition indebtedness.

A taxpayer is allowed the tax credit for a purchase of one eligible single-family residence made between June 1, 2009 and November 30, 2009. The credit amount is the lesser of 1.2 percent of the purchase price of the eligible single-family residence or $1,800.00. The amount of the tax credit that may be claimed and allowed in a single tax year cannot exceed the lesser of 1/3 of the credit or the taxpayer’s income tax liability. Any unused tax credit can be carried forward but cannot be carried back.

The taxpayer must have claimed the credit in 2009 in order to claim the unused credit below.

1. Total credit. (Enter amount from 2009 IND-CR, Part 9, Line 5.)...0.. eee eens 1. 5 . 00 2.Maximum allowed per year..........cccceecec ccc essceeeceeceeccecseeseeseeeseeecaeseesseeseeeeeees 2. 33 % 3. Maximum credit allowed, (multiply Line 1 by Line 2)........ elec ee eeeeeeeeeeeeeeeeeeeees 3 ; . 00 4. Enter unused credit (Total credit less amounts used in previous years).............0 4. ; . 00 5. Credit allowed, lesser of Line 3 OF LINE 4.0.........ccc ccc cccecsecccesesseeeceeesssseeeeessseseesesssaeeee 5. ; . 00 6. Credit used this tax year (enter here and include on IND-CR Summary Worksheet

LiM© Q)..esceccesssesesssssessssvessssseecsssecsssssessssuevecssvecsssevecsssecssssuessssusessssuesssuvstssseessssvesssseeess 6. ; _ 00 7. Carryover to next tax year (Line 4 less Line 6)... cece ceeeeeeeeeeeeeeeeeeeeeeeeeeeeneneeenee 7 . 00

| P | rorm IND-CR 212 age 4 State of Georgia Individual Credit Form Georgia Department of Revenue 2244405915 2021 (Rev. 08/02/21) (Approved booklet version) . . — Include with Form 500 or 500X, if this schedule is applicable. — YOUR SOCIAL SECURITY NUMBER

> SCHEDULE 212 Community Based Faculty Preceptor Tax Credit - Tax Credit 212

Community Based Faculty Preceptor Tax Credit - Tax Credit 212

0.C.G.A. § 48-7-29.22 provides an income tax credit for a community based faculty preceptor that conducts a preceptorship

rotation(s). This tax credit is applicable for taxable years beginning on or after January 1, 2019 and ending on

or before December 31, 2023.

For a community based faculty preceptor who is a physician as defined in O.C.G.A. § 43-34-21, the credit shall accrue on a per

preceptorship rotation basis in the amount of $500 for the first, second, or third preceptorship rotation and $1,000 for the fourth, fifth, sixth, seventh, eighth, ninth, or tenth preceptorship rotation completed in one calendar year. For a community based faculty preceptor who is an advanced practice registered nursed as defined in O.C.G.A. § 43-26-3 or a physician assistant as defined in 0.C.G.A. § 43-34-102, the credit shall accrue on a per preceptorship rotation basis in the amount of $375 for the first, second, or third preceptorship rotation and $750 for the fourth, fifth, sixth, seventh, eighth, ninth, or tenth preceptorship rotation completed in one calendar year. An individual shall not accrue credit for more than ten preceptorship rotations in one calendar year. The credit cannot be carried forward and cannot be carried back. Certification from the Area Health Education Centers Program Office at Augusta University

must be enclosed with the return.

By filing this form | certify that | did not receive payment during such tax year from any source for the training of a medical student,

advanced practice registered nurse student, or physician assistant student.

A. Community Based Faculty Preceptor Tax Credit for a physician

First through Third Rotation

1. Number of Rotations (enter no more than 3) L] x e) 0 0 . 00 (Mot to Exceed $1,500)... ceeccceceseeeeeeseeeesesteeeeeeeeeesetees

Fourth through Tenth Rotation

2. Number of Rotations (enter no more than 7) LJ Xx (1 , 0 0 0 . 00 (Mot to Exceed $7,000) ....seeeeeecececceceseeeeeeseeeeesteeeseeeeeseeteeeeeaees

3. Add Line 1 and Line 2, Current Year Credit Amount (cannot exceed $8,500).............

B. Community Based Faculty Preceptor Tax Credit for an advanced practice registered nurse or physician assistant.

First through Third Rotation

1. Number of Rotations (enter no more than 3) L] x 3 7 i) " 00 (not to Exceed $1,125)... eeceecececeeeecesceeeeeeeeeeseeteeeeeneeeees

Fourth through Tenth Rotation

2. Number of Rotations (enter no more than 7) L] x 7 i) 0 . 00 (Not to Exceed $5,250)... .ececceceesceceeeeeseeeteeeeseeeeeeeteeees

3. Add Line 1 and Line 2, Current Year Credit Amount (cannot exceed $6,375)..........--

C. Community Based Faculty Preceptor Tax Credit Total 1.Credit used this year (enter no more than the total of Line A3 and Line B3)(enter here and include on IND-CR Summary Worksheet Line 10)... cceeeeeeeseeseeeteeeeeeneeeneees

| rom IND-CR 213 | | ll

State of Georgia Individual Credit Form | | | l | | | il

Georgia Department of Revenue 2244505915 2021 (Rev. 08/02/21) (Approved booklet version)

— Include with Form 500 or 500X, if this schedule is applicable. —

Page |

YOUR SOCIAL SECURITY NUMBER

» SCHEDULE 213 Adoption of a Foster Child Credit for Adoptions Occurring in Taxable Years Beginning on or After

January 1, 2021 - Tax Credit 213

Adoption of a Foster Child Credit for Adoptions Occurring in Taxable Years Beginning on or After

January 1, 2021- Tax Credit 213

0.C.G.A. § 48-7-29.15 provides an income tax credit for the adoption of a qualified foster child. This credit applies to adoptions occurring in taxable years beginning on or after January 1, 2021. The amount of the credit is $6,000 per qualified foster child per taxable year, commencing with the year in which the adoption becomes final, for five taxable years and $2,000 per qualified foster child per taxable year thereafter, and ending in the year in which the adopted child

attains the age of 18. This credit cannot be carried forward.

1. Enter $6,000 per qualified foster child (if in first five taxable years

Of the AGOPTION) 0... eee cee eeee eee tee teeter eeeeeeeeeseeeeeeeeeeseesneeeeeseeeneees 1. 2. Enter $2,000 per qualified foster child (for years after first five

taxable years Of AdOption)........ eee eeee eee eeeeteeeeeteeeteeeeeteeeteteeeteeeees 2. 3. Add Line 1 and Line 2, Current Year Credit Amount ...............0c::cccceeeee 3.

4. Credit used this year (enter no more than the amount on line 3)(enter here and include on IND-CR Summary Worksheet Line 11).............. 4.

00

| Georgia Form IN D-C R Summary Worksheet (Rev. 08/02/21)

State of Georgia Individual Credit Form 2205905915 Georgia Department of Revenue

Page |

2021 (Approved booklet version)

YOUR SOCIAL SECURITY NUMBER

1. Only Georgia Individual Tax Credits (series 200) are claimed on Form IND-CR supporting schedules (IND-CR 201 through 213).

2. Enter the amount of credit used for the current tax year from each applicable IND-CR schedules on Lines 1-11.

3. If there is a credit remaining from previous years eligible for carryover for this tax year, the supporting IND-CR

schedule must be completed even if the credit is not used for this tax year.

4. The total of Line 12 should be entered on Form 500 or Form 500X, Page 3, Line 19.

5. All applicable IND-CR schedules must be attached to Form 500 or Form 500X for the credit(s) to be allowed on the return.

Note: The other state(s) tax credit and low income credit are claimed directly on Form 500. Series 100 Georgia tax

credits (except Schedule 2B refundable tax credits) are claimed on Form 500 Schedule 2 and returns that include the

series 100 credits must be filed electronically.

The total credit amount used from the low income credit, the other state(s) tax credit, all IND-CR schedules, and all

Schedule 2s cannot exceed the tax liability listed on Line 16 of Form 500 or 500X.

IND-CR SUMMARY SCHEDULE WORKSHEET |

1. Disabled Person Home Purchase or Retrofit Credit (IND-CR 201, Line 3) ............ 1. 5 . 00 2. Child and Dependent Care Expense Credit (IND-CR 202, Line 4) .... 2 5 . 00 3. Georgia National Guard /Air National Guard Credit (IND-CR 203, Line 3) ............ 3. 5 . 00 4. Qualified Caregiving Expense Credit (IND-CR 204, Line 6) .........0... ee 4. 5 . 00 5. Reserved . . 5. 6. Disaster Assistance Credit (IND-CR 206, Line 6)... eect eee eerereneeeeee 6. 5 . 00 7. Rural Physicians Credit (IND-CR 207, Line 7) .......0... cece eee eeeeceeeeeeeeteeneaeees 7. 5 . 00 8. Adoption of a Foster Child Credit for Adoptions Occurring in Taxable Years Beginning on or After January 1, 2008 and Before January 1, 2021 (IND-CR 208, Line 3)... cece eeceeeeneeeeeeeeeeeceeeeseeeeeeteneeeneeseseeteeeteeseeeeeetaneteees 8. ) . 0 9. Eligible Single-Family Residence Credit (IND-CR 209, Line 6) .............. ee 9. 5 . 00 10. Community Based Faculty Preceptor Credit (IND-CR 212, Line C1) «0... 10. ) . 00 11. Adoption of a Foster Child Credit for Adoptions Occurring in Taxable Years Beginning on or After January 1, 2021 (IND-CR 213, Line 4)... eee 11. 5 . 00 12. Total of Lines 1 through 11 (Enter here and on Form 500/500X, Page 3 Line 19) 12. 5 . 00

All applicable IND-CR Schedules (201, etc.) must be attached to Form 500 or Form 500X.

Keep IND-CR Summary Worksheet for your records.

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| ll ll | | | IK | | | HI Please print your numbers like this in black or blue ink:]

2200205913 = le al clea Ge o- ee a Jes i oe Georgia Form 500EZ (Rev. 05/25/21) _ _ Short Individual Income Tax Return YOUR SSN# Georgia Department of Revenue 2021 (Approved booklet version) - - SPOUSE’S SSN# Page 1 STATE YOUR DRIVER’S ISSUED LICENSE/STATE ID YOUR FIRST NAME MI LAST NAME (For Name Change See IT-511 Tax Booklet) SUFFIX SPOUSE’S FIRST NAME MI LAST NAME SUFFIX

ADDRESS (NUMBER AND STREET or P.O. BOX) (Use 2nd address line for Apt, Suite or Building Number) O CHECK IF ADDRESS CHANGED

DEPARTMENT USE ONLY

CITY (Please insert a space if the city has multiple names) STATE ZIP CODE (COUNTRY IF FOREIGN) Use Federal Adjusted Gross Income, NOT Federal Taxable Income, on Line 1 below 1. Adjusted Gross Income from Federal Form 1040 (Cannot exceed $99,999 for Line 1)............0:::cee 1. 5 . 00 2. If your filing status is single, enter $7,300.00, married filing joint, enter $13,400.00 oo... eeeeceeseeseesecsesseesenentenseeee 2. ) . 00 3. Subtract Line 2 from Line 1. If Line 2is larger than Line 1, enter ZOrO .........scescescessesseesseesseessecssseessensssnseesnsee 3. ) . 00 4.Find the tax on the amount on Line 3. (Use the Tax Table or tax rate schedule in the IT-511 Tax Booklet)........ 4. ; . 00 5. Lowincome tax credit. (Not allowed if you are claimed as a dependent on another return) 5a. 5b. 5c. . 00 6. Subtract Line 5c from Line 4. If zero or less than Zero, ENteP ZELO........ cece tees ees eesees testes eeseeseesete 6. ) . 00 "PLEASE COMPLETE INCOME STATEMENT DETAILSON PAGE 3. ns ses) “rn : ’ 00 8. IfLine 6 is larger than Line 7, subtract Line 7 from Line 6. THE AMOUNT OF TAX YOU OWE.................. 8. ) . 00 9. IfLine 7 is larger than Line 6, subtract Line 6 from Line 7. THE AMOUNT OF YOUR OVERPAYMENT........... 9. 5 . 00 10. Georgia Wildlife Conservation Fund (No gift less than $1.00)... escent 10. ) . 00 11.. Georgia Fund for Children and Elderly (No gift less than $1.00) ....0..0....ccccecccsecseeseesteseesteseeteseeseeeeeseeeee 11. 5 . 00 12. Georgia Cancer Research Fund (No gift less than $1.00)... lessees nesses 12. ) . 00 13. Georgia Land Conservation Program (No gift less than $1.00)...0.0.......ccccssssssssssscssssssssesesesuuuussssssestee 13, ) . 00 14. Georgia National Guard Foundation (No gift less than $1.00)... eeeeseeseesessneeeeeneesnane 14. ; . 00 15. Dog and Cat Sterilization Fund (No gift less than $1.00) 0.0.0... eee 15. 5 . 00 = Saving the Cure Fund (No gift less thar $1.00)..0.........cccceccsceceseseeseeeseesessesteseeneseeseeneseetesteseetentennennes 16. ; . =

; UAT : Z

Georgia Form 500 2200205923 Short Individual Income Tax Return YOUR SOCIAL SECURITY NUMBER Georgia Department of Revenue

2021

Page 2 17. Realizing Educational Achievement Can Happen (REACH) Program (No gift less than $1.00)......... 17. ; . 00 18. Public Safety Memorial Grant (No gift less than $1.00) 0.000... ee eeeeseesnesiesesseneesneseee 18, ; . 00 19. Add Lines 10 thru Line 18, enter total N@re.......c.cccccccccsccsscssscsescscsescsescscscscecscecscscsvecsvscsescscseseecaveeseeteeseeetes 19. ) 00 20. (If you owe) Add Line 8 and Line 19. Complete and mail 525-TV with return and payment Make check for this amount payable to the GEORGIA DEPARTMENT OF REVENUE..................... 20. 00 mount Due Mail To: , GEORGIA DEPARTMENT OF REVENUE PROCESSING CENTER, PO BOX 740399 TLANTA, GA 30374-0399 21. (If you are due a refund) Subtract Line 19 from Line 9. THIS IS YOUR REFUND.............0..00ccee 21. 00 If you do not enter Direct Deposit information or if you are a first time filer you will be issued a paper check. atund Due Mail = . 21a. Direct Deposit (For U.S. Accounts Only) GEORGIA DEPARTMENT OF REVENUE Routing PROCESSING CENTER, PO BOX 740380 Type: Checking L] savings [] Number ATLANTA, GA 30374-0380 Account Number

\/We declare under 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.

Taxpayer’s Signature Oo (Check box if deceased) Spouse’s Signature (1 (Check box if deceased) Taxpayer's Date of Death Spouse’s Date of Death Taxpayer's Signature Date Taxpayer's Phone Number Spouse's Signature Date

By providing my e-mail address | am authorizing the Georgia Department of Revenue to electronically notify me at the below e-mail address regarding any updates to my account(s).

Taxpayer’s E-mail Address |

| authorize DOR to discuss this return with the named preparer.

Preparer’s Phone Number

Signature of Preparer

Name of Preparer Other Than Taxpayer Preparer’s FEIN

Preparer’s Firm Name Preparers SSN/PTIN/SIDN

PLEASE COMPLETE INCOME STATEMENT DETAILS ON PAGE 3.

|| ALL PAGES (1-3) ARE REQUIRED FOR PROCESSING |

Georgia Form 500EZ 2200205933 Short Individual Income Tax Return YOUR SOCIAL SECURITY NUMBER

Georgia Department of Revenue . .

2021 Page 3

)income STATEMENT DETAILS Only enter income on which Georgia tax was withheld. Enter information from W-2s and 1099s in the section below.

(INCOME STATEMENT A) (INCOME STATEMENT B) (INCOME STATEMENT C) 1. WITHHOLDING TyPE: [] w-2 []1099 1. wiTHHOLDING TYPE: [-] w-2 [] 1099 1. wiTHHOLDINGTYPE: [] w-2 [] 1099

2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL 2. EMPLOYERI/PAYER FEDERAL ID NUMBER (FEIN) [] ssn[] ID NUMBER (FEIN) [[] ssn [] ID NUMBER (FEIN) [[] ssn [1]

3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID

4. GAWAGES/ INCOME 4. GAWAGES/ INCOME 4. GA WAGES / INCOME , 00 ; 00 , 00 5. GA TAX WITHHELD 5. GA TAX WITHHELD 5. GA TAX WITHHELD 00 00 00 (INCOME STATEMENT D) (INCOME STATEMENT E) (INCOME STATEMENT F)

WITHHOLDING TYPE: Oo W-2 Oo 1099

4. witHHoLpine Type: LC] w-2 [] 1099 1. witHHoLoiINctype: [] w-2 [] 1099

2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL 2. EMPLOYERI/PAYER FEDERAL ID NUMBER (FEIN) [] ssn[] ID NUMBER (FEIN) [] ssn [] ID NUMBER (FEIN) [.] ssn [1]

3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID

4. GAWAGES/ INCOME 4. GA WAGES / INCOME 4. GA WAGES / INCOME

, 00 ; 00 , 00 5. GA TAX WITHHELD 5. GA TAX WITHHELD 5. GA TAX WITHHELD

00 00 00

YOU MAY USE FORM 500EZ IF:

=m You are not 65 or over, or blind.

Your filing status is single or married filing joint and you do not claim any exemptions other than yourself or yourself and your spouse.

Your income does not exceed $99,999 and you do not itemize deductions.

You are a full-year Georgia resident.

You had wages, salaries, tips, dividends, and interest income only. Do not use this form if you paid or are claiming a credit of estimated tax or the timber tax credit.

= You do not have any adjustments to Federal Adjusted Gross Income.

WHEN COMPLETING YOUR RETURN PLEASE REMEMBER TO:

u Print or type name(s), address and social security number(s).

mu Keep numbers inside boxes.

mu Donotuse dollar signs, commas or decimals. Round off figures for easier computations. These have been preprinted for your convenience. u Sign and date your return. See IT-511 Tax Booklet for signature requirements.

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Georgia Tax Rate Schedule

A taxpayer can use the tax tables starting on page 53 or the Georgia Tax Rate Schedule below. See page 50 and 51 for the worksheet and examples.

Single

If Georgia Taxable Income Is (Line 15c Form 500/500X or Line 3 Form 500EZ)

Amount of Tax Is

Column A Column B Column C Column D Column E Over But not over $0 $750 1% of taxable income $750 $2,250 $8.00 | Plus 2% of the amount over $750 $2,250 $3,750 $38.00 | Plus 3% of the amount over $2,250 $3,750 $5,250 $83.00 | Plus 4% of the amount over $3,750 $5,250 $7,000 $143.00 | Plus 5% of the amount over $5,250 $7,000 $230.00 | Plus 5.75% of the amount over $7,000 Married Filing Joint or Head of Household If Georgia Taxable Income Is Amount of Tax Is (Line 15c Form 500/500X or Line 3 Form 500EZ) Column A Column B Column C Column D Column E Over But not over $0 $1,000 1% of taxable income $1,000 $3,000 $10.00 | Plus 2% of the amount over $1,000 $3,000 $5,000 $50.00 | Plus 3% of the amount over $3,000 $5,000 $7,000 $110.00} Plus 4% of the amount over $5,000 $7,000 $10,000 $190.00 | Plus 5% of the amount over $7,000 $10,000 $340.00 | Plus 5.75% of the amount over $10,000 Married Filing Separate If Georgia Taxable Income Is Amount of Tax Is (Line 15c Form 500/500X or Line 3 Form 500EZ) Column A Column B Column C Column D Column E Over But not over $0 $500 1% of taxable income $500 $1,500 $5.00 | Plus 2% of the amount over $500 $1,500 $2,500 $25.00 | Plus 3% of the amount over $1,500 $2,500 $3,500 $55.00 | Plus 4% of the amount over $2,500 $3,500 $5,000 $95.00 | Plus 5% of the amount over $3,500 $5,000 $170.00 | Plus 5.75% of the amount over $5,000

Page 49

A taxpayer can use the tax tables starting on page 53 or the taxpayer may use the Georgia Tax Rate Schedule. The following worksheet is used to compute your tax liability using the Georgia Tax Rate Schedule. Also please see the examples below the worksheet.

Georgia Tax Rate Worksheet

1. Amount from Form 500, Line 15c or Form 500EZ, Line 3 $

2. Using the tables above, locate your filing status and Georgia $ taxable income range. Enter the amount from Column E for that Range

Subtract Line 2 from Line 1 $

Enter the percentage from Column D % Multiply Line 3 by Line 4

Enter the amount from Column C

NN} OP) a RL &

Add Line 5 and Line 6. Enter amount here and on Form 500, Line 16 or Form 500EZ, Line 4.

Example 1: Single

Your filing status is Single with a taxable income of $5,125. Your tax amount is $138 based on the calculations below. The amounts were rounded to the nearest dollar.

The applicable portion of the Georgia Tax Rate Schedule is as follows:

Single

If Georgia Taxable Income Is Amount of Tax Is

(Line 15c Form 500/500X or Line 3 Form 500EZ)

Column A Column B Column C Column D Column E Over But not over $3,750 $5,250 $83.00 | Plus 4% of the amount over $3,750

Using the worksheet the tax is computed as follows:

1. Amount from Form 500, Line 15c or Form 500EZ, Line 3 $ 5,125 2. Using the tables above, locate your filing status and Georgia $ 3,750 taxable income range. Enter the amount from Column E for that range 3. Subtract Line 2 from Line 1 $ 1,375 4. Enter the percentage from Column D 4% 5. Multiply Line 3 by Line 4 $ 55 6. Enter the amount from Column C $ 83 7. Add Line 5 and Line 6. Enter amount here and on Form 500, $ 138 Line 16 or Form 500EZ, Line 4.

Page 50

Example 2: Married Filing Joint

Your filing status is Married Filing Joint with a taxable income of $77,878. Your tax amount is

$4,243 based on the calculations below. The amounts were rounded to the nearest dollar.

The applicable portion of the Georgia Tax Rate Schedule is as follows:

Married Filing Joint or Head of Household

If Georgia Taxable Income Is

(Line 15c Form 500/500X or Line 3 Form 500EZ)

Amount of Tax Is

Column A Column B Column C Column D Column E Over But not over $10,000 $340.00 | Plus 5.75% of the amount over $10,000

Using the worksheet the tax is computed as follows:

1. Amount from Form 500, Line 15c or Form 500EZ, Line 3 $ 77,878 2. Using the tables above, locate your filing status and Georgia $ 10,000 taxable income range. Enter the amount from Column E for that range 3. Subtract Line 2 from Line 1 $ 67,878 4. Enter the percentage from Column D 5.75 % 5. Multiply Line 3 by Line 4 $ 3,903 6. Enter the amount from Column C $ 340 7. Add Line 5 and Line 6. Enter amount here and on Form 500, $ 4,243

Line 16 or Form 500EZ, Line 4.

Page 51

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Page 52

This amount should be placed on Line 16, Form 500 or Line 4, Form 500EZ

GEORGIA INCOME TAX TABLE

Line 15c, Form

Line 15¢, Form 500

Line 15c, Form 500

Line 15¢, Form 500

Line 15c, Form 500

500 or Married or Married or Line 3, Form Married or Line 3, Form Married or Line 3, Form Married Line 3, Form Filing Line 3, Form 500EZ 500EZ Filing 500EZ Filing 500EZ Filing SOVEZ. Jointly or | married Jointly or | married Jointly or | married Jointly or | married Jointly or | married at |ButLess Neadof | Fira | at |But Less; Neadof | Fiing | at | ButLess teadof | Fine | at [But Less Neadof | Fitna | at |But Less wager | fuina east | Than |singie| noid | rately | “east | TM Isingie| ord | ratoy | east | Than | singie| hold | rately | Least | ThAM | singe] hold | ratay | be*S* | TH | single] hold | rately 7,000, 14,000 21,000 28,000. $0 100] 0 0 0 | 7,000 7,100f 233] 193 | 288 [14,000 14,100] 635 ] 573 | 690 | 21,000 21,100] 1,038] 975 | 1,093] 28,000 28,100] 1,440] 1,378 | 1,495 100 200} 2 2 2 | 7,100 7,200] 239] 198 | 294 14,100 14,200] 641 | 579 | 696 | 21,100 21,200] 1,044) 981 | 1,099] 28,100 28,200] 1,446] 1,384 | 1,501 200 300] 3 3 3 | 7,200 7,300] 244] 203 | 299 |14,200 14,300] 647 | 584 | 702 | 21,200 21,300] 1,049] 987 | 1,104] 28,200 28,300] 1,452] 1,389 | 1,507 300 400] 4 4 4 | 7,300 7,400] 250} 208 | 305 |14,300 14,400] 653 | 590 | 708 | 21,300 21,400] 1,055] 993 | 1,110] 28,300 28,400] 1,458] 1,395 | 1,513 400 500] 5 5 5 | 7,400 7,500] 256] 213 | 311 |14,400 14,500] 658 | 596 | 713 | 21,400 21,500] 1,061) 998 | 1,116] 28,400 28,500] 1,463] 1,401 | 1,518 500 600] 6 6 6 | 7,500 7,600] 262] 218 | 317 |14,500 14,600] 664 | 602 | 719 | 21,500 21,600] 1,067) 1,004 | 1,122] 28,500 28,600] 1,469] 1,407 | 1,524 600 700] 7 7 8 | 7,600 7,700] 267| 223 | 322 |14,600 14,700] 670 | 607 | 725 | 21,600 21,700] 1,072] 1,010 | 1,127] 28,600 28,700] 1,475] 1,412 | 1,530 700 800] 8 8 10 | 7,700 7,800] 273] 228 | 328 |14,700 14,800] 676 | 613 | 731 | 21,700 21,800] 1,078} 1,016 | 1,133] 28,700 28,800] 1,481] 1,418 | 1,536 800 900] 10] 9 12 | 7,800 7,900] 279] 233 | 334 |14,800 14,900] 681 | 619 | 736 | 21,800 21,900} 1,084] 1,021 | 1,139] 28,800 28,900] 1,486] 1,424 | 1,541 900 1,000} 12 | 10 14_| 7,900 8,000] 285] 238 | 340 |14,900 15,000] 687 | 625 | 742 | 21,900 22,000} 1,090} 1,027 | 1,145] 28,900 29,000} 1,492] 1,430 | 1,547 7,000 8,000 75,000 22,000 29,000 1,000 1,100] 14] 11 16 | 8,000 8,100] 290] 243 | 345 [15,000 15,100] 693] 630 | 748 | 22,000 22,100] 1,095] 1,033 | 1,150] 29,000 29,100] 1,498] 1,435 | 1,553 1,100 1,200} 16) 13 | 18 | 8,100 8,200] 296] 248 | 351 |15,100 15,200] 699 | 636 | 754 | 22,100 22,200] 1,101] 1,039 | 1,156] 29,100 29,200] 1,504] 1,441 | 1,559 1,200 1,300} 18) 15 | 20 | 8,200 8,300] 302] 253 | 357 |15,200 15,300] 704 | 642 | 759 | 22,200 22,300] 1,107} 1,044 | 1,162] 29,200 29,300] 1,509] 1,447 | 1,564 1,300 1,400} 20) 17 | 22 | 8,300 8,400] 308] 258 | 363 |15,300 15,400] 710 | 648 | 765 | 22,300 22,400] 1,113] 1,050 | 1,168] 29,300 29,400] 1,515] 1,453 | 1,570 1,400 1,500} 22) 19 | 24 | 8400 8,500] 313] 263 | 368 | 15,400 15,500] 716 | 653 | 771 | 22,400 22,500] 1,118] 1,056 | 1,173] 29,400 29,500] 1,521] 1,458 | 1,576 1,500 1,600) 24] 21 27 | 8,500 8,600] 319| 268 | 374 |15,500 15,600] 722 | 659 | 777 | 22,500 22,600] 1,124] 1,062 | 1,179] 29,500 29,600] 1,527] 1,464 | 1,582 1,600 1,700} 26) 23 | 30 | 8,600 8,700] 325] 273 | 380 |15,600 15,700] 727 | 665 | 782 | 22,600 22,700] 1,130] 1,067 | 1,185] 29,600 29,700} 1,532] 1,470 | 1,587 1,700 1,800] 28) 25 | 33 | 8,700 8,800] 331] 278 | 386 |15,700 15,800] 733 | 671 | 788 | 22,700 22,800] 1,136] 1,073 | 1,191] 29,700 29,800] 1,538] 1,476 | 1,593 1,800 1,900} 30) 27 | 36 | 8800 8,900] 336] 283 | 391 |15,800 15,900] 739 | 676 | 794 | 22,800 22,900] 1,141] 1,079 | 1,196] 29,800 29,900} 1,544] 1,481 | 1,599 1,900 2,000} 32 | 29 | 39 | 8,900 9,000] 342] 288 | 397 | 15,900 16,000] 745 | 682 | 800 | 22,900 23,000] 1,147] 1,085 | 1,202] 29,900 30,000} 1,550] 1,487 | 1,605 2,000 9,000 76,000 23,000 30,000 2,000 2,100] 34] 31 42 | 9,000 9,100] 348] 293 ] 403 [16,000 16,100] 750] 688 | 805 | 23,000 23,100] 1,153] 1,090 ] 1,208] 30,000 30,100] 1,555] 1,493 | 1,610 2,100 2,200] 36} 33 | 45 | 9,100 9,200] 354] 298 | 409 |16,100 16,200] 756 | 694 | 811 | 23,100 23,200] 1,159] 1,096 | 1,214] 30,100 30,200] 1,561] 1,499 | 1,616 2,200 2,300] 38 | 35 | 48 | 9,200 9,300) 359] 303 | 414 |16,200 16,300] 762 | 699 | 817 | 23,200 23,300] 1,164] 1,102 | 1,219] 30,200 30,300] 1,567) 1,504 | 1,622 2,300 2,400] 41| 37 | 51 | 9,300 9,400] 365] 308 | 420 |16,300 16,400] 768 | 705 | 823 | 23,300 23,400] 1,170] 1,108 | 1,225] 30,300 30,400] 1,573] 1,510 | 1,628 2,400 2,500] 44] 39 | 54 | 9,400 9,500] 371| 313 | 426 |16,400 16,500) 773 | 711 | 828 | 23,400 23,500] 1,176| 1,113 | 1,231] 30,400 30,500] 1,578] 1,516 | 1,633 2,500 2,600] 47] 41 57 | 9,500 9,600] 377| 318 | 432 |16,500 16,600] 779 | 717 | 834 | 23,500 23,600] 1,182| 1,119 | 1,237] 30,500 30,600] 1,584] 1,522 | 1,639 2,600 2,700] 50] 43 | 61 | 9,600 9,700] 382] 323 | 437 |16,600 16,700] 785 | 722 | 840 | 23,600 23,700] 1,187| 1,125 | 1,242] 30,600 30,700] 1,590] 1,527 | 1,645 2,700 2,800] 53 | 45 | 65 | 9,700 9,800] 388] 328 | 443 | 16,700 16,800] 791 | 728 | 846 | 23,700 23,800] 1,193] 1,131 | 1,248] 30,700 30,800] 1,596] 1,533 | 1,651 2,800 2,900] 56 | 47 | 69 | 9,800 9,900] 394] 333 | 449 |16,800 16,900] 796 | 734 | 851 | 23,800 23,900] 1,199] 1,136 | 1,254] 30,800 30,900] 1,601] 1,539 | 1,656 2,900 3,000] 59 | 49 | 73 | 9,900 10,000] 400| 338 | 455 | 16,900 17,000] 802 | 740 | 857 | 23,900 24,000] 1,205| 1,142 | 1,260] 30,900 31,000] 1,607] 1,545 | 1,662 3,000 70,000, 77,000 24,000 31,000 3,000 3,100] 62] 52 | 77 | 10,000 10,100] 405] 343 | 460 |17,000 17,100] 808] 745 | 863 | 24,000 24,100] 1,210] 1,148 | 1,265] 31,000 31,100] 1,613] 1,550 | 1,668 3,100 3,200] 65} 55 | 81 | 10,100 10,200] 411] 349 | 466 |17,100 17,200] 814 | 751 | 869 | 24,100 24,200] 1,216] 1,154 | 1,271] 31,100 31,200] 1,619] 1,556 | 1,674 3,200 3,300] 68 | 58 | 85 | 10,200 10,300] 417| 354 | 472 |17,200 17,300] 819 | 757 | 874 | 24,200 24,300] 1,222| 1,159 | 1,277] 31,200 31,300] 1,624] 1,562 | 1,679 3,300 3,400] 71] 61 89 | 10,300 10,400] 423] 360 | 478 |17,300 17,400] 825 | 763 | 880 | 24,300 24,400] 1,228] 1,165 | 1,283] 31,300 31,400] 1,630] 1,568 | 1,685 3,400 3,500] 74] 64 | 93 | 10,400 10,500] 428] 366 | 483 | 17,400 17,500} 831 | 768 | 886 | 24,400 24,500] 1,233] 1,171 | 1,288] 31,400 31,500] 1,636] 1,573 | 1,691 3,500 3,600] 77] 67 | 98 | 10,500 10,600] 434] 372 | 489 |17,500 17,600] 837 | 774 | 892 | 24,500 24,600] 1,239] 1,177 | 1,294] 31,500 31,600] 1,642] 1,579 | 1,697 3,600 3,700] 80} 70 | 103 }10,600 10,700] 440| 377 | 495 |17,600 17,700] 842 | 780 | 897 | 24,600 24,700] 1,245] 1,182 | 1,300] 31,600 31,700] 1,647] 1,585 | 1,702 3,700 3,800] 83 | 73 | 108 }10,700 10,800] 446] 383 | 501 |17,700 17,800] 848 | 786 | 903 | 24,700 24,800] 1,251] 1,188 | 1,306] 31,700 31,800] 1,653] 1,591 | 1,708 3,800 3,900] 87 | 76 | 113 | 10,800 10,900] 451] 389 | 506 |17,800 17,900] 854 | 791 | 909 | 24,800 24,900] 1,256] 1,194 | 1,311] 31,800 31,900] 1,659] 1,596 | 1,714 3,900 4,000] 91 | 79 | 118 |10,900 11,000] 457| 395 | 512 | 17,900 18,000] 860 | 797 | 915 | 24,900 25,000] 1,262| 1,200 | 1,317] 31,900 32,000] 1,665] 1,602 | 1,720 4,000 77,000 78,000 25,000 32,000 4,000 4,100] 95] 82 | 123 [11,000 11,100] 463] 400 | 518 [18,000 18,100] 865] 803 | 920 | 25,000 25,100] 1,268] 1,205 | 1,323] 32,000 32,100] 1,670) 1,608 | 1,725 4,100 4,200] 99 | 85 | 128 |11,100 11,200] 469] 406 | 524 | 18,100 18,200] 871 | 809 | 926 | 25,100 25,200] 1,274] 1,211 | 1,329] 32,100 32,200] 1,676] 1,614 | 1,731 4,200 4,300] 103] 88 | 133 |11,200 11,300] 474] 412 | 529 |18,200 18,300] 877 | 814 | 932 | 25,200 25,300] 1,279] 1,217 | 1,334] 32,200 32,300] 1,682] 1,619 | 1,737 4,300 4,400] 107| 91 | 138 |11,300 11,400] 480] 418 | 535 |18,300 18,400] 883 | 820 | 938 | 25,300 25,400] 1,285] 1,223 | 1,340] 32,300 32,400] 1,688] 1,625 | 1,743 4,400 4,500] 111] 94 | 143 |11,400 11,500] 486] 423 | 541 | 18,400 18,500] 888 | 826 | 943 | 25,400 25,500] 1,291] 1,228 | 1,346] 32,400 32,500] 1,693] 1,631 | 1,748 4,500 4,600] 115] 97 | 148 |11,500 11,600] 492] 429 | 547 |18,500 18,600] 894 | 832 | 949 | 25,500 25,600] 1,297] 1,234 | 1,352] 32,500 32,600] 1,699] 1,637 | 1,754 4,600 4,700] 119] 100 | 153 | 11,600 11,700] 497] 435 | 552 | 18,600 18,700] 900 | 837 | 955 | 25,600 25,700] 1,302] 1,240 | 1,357] 32,600 32,700] 1,705] 1,642 | 1,760 4,700 4,800] 123] 103 | 158 |11,700 11,800] 503] 441 | 558 |18,700 18,800] 906 | 843 | 961 | 25,700 25,800] 1,308] 1,246 | 1,363] 32,700 32,800] 1,711] 1,648 | 1,766 4,800 4,900] 127| 106 | 163 |11,800 11,900] 509] 446 | 564 | 18,800 18,900] 911 | 849 | 966 | 25,800 25,900] 1,314] 1,251 | 1,369] 32,800 32,900] 1,716] 1,654 | 1,771 4,900 5,000] 131] 109 | 168 |11,900 12,000] 515| 452 | 570 |18,900 19,000] 917 | 855 _| 972 | 25,900 26,000} 1,320| 1,257 | 1,375] 32,900 33,000] 1,722| 1,660 | 1,777 5,000 72,000 79,000 26,000 33,000 5,000 5,100] 135] 112 | 173 |12,000 12,100] 520] 458 | 575 |19,000 19,100] 923] 860 | 978 | 26,000 26,100] 1,325] 1,263 | 1,380] 33,000 33,100] 1,728] 1,665 | 1,783 5,100 5,200] 139} 116 | 179 |12,100 12,200] 526] 464 | 581 |19,100 19,200] 929 | 866 | 984 | 26,100 26,200] 1,331] 1,269 | 1,386] 33,100 33,200] 1,734] 1,671 | 1,789 5,200 5,300] 143] 120 | 184 }12,200 12,300] 532] 469 | 587 |19,200 19,300] 934 | 872 | 989 | 26,200 26,300] 1,337| 1,274 | 1,392] 33,200 33,300] 1,739] 1,677 | 1,794 5,300 5,400] 148] 124 | 190 |12,300 12,400] 538] 475 | 593 |19,300 19,400] 940 | 878 | 995 | 26,300 26,400] 1,343] 1,280 | 1,398] 33,300 33,400] 1,745] 1,683 | 1,800 5,400 5,500] 153] 128 | 196 }12,400 12,500] 543| 481 | 598 |19,400 19,500] 946 | 883 | 1,001] 26,400 26,500] 1,348] 1,286 | 1,403] 33,400 33,500] 1,751] 1,688 | 1,806 5,500 5,600] 158] 132 | 202 }12,500 12,600] 549| 487 | 604 | 19,500 19,600] 952 | 889 | 1,007] 26,500 26,600] 1,354] 1,292 | 1,409] 33,500 33,600] 1,757] 1,694 | 1,812 5,600 5,700] 163] 136 | 207 }12,600 12,700] 555| 492 | 610 |19,600 19,700] 957 | 895 | 1,012] 26,600 26,700] 1,360] 1,297 | 1,415] 33,600 33,700] 1,762] 1,700 | 1,817 5,700 5,800] 168] 140 | 213 | 12,700 12,800] 561| 498 | 616 |19,700 19,800} 963 | 901 | 1,018] 26,700 26,800] 1,366] 1,303 | 1,421] 33,700 33,800] 1,768] 1,706 | 1,823 5,800 5,900] 173] 144 | 219 |12,800 12,900] 566] 504 | 621 |19,800 19,900] 969 | 906 | 1,024] 26,800 26,900] 1,371] 1,309 | 1,426] 33,800 33,900] 1,774] 1,711 | 1,829 5,900 6,000] 178] 148 | 225 | 12,900 13,000] 572| 510 | 627 | 19,900 20,000] 975 | 912 | 1,030] 26,900 27,000] 1,377| 1,315 | 1,432] 33,900 34,000] 1,780] 1,717 | 1,835 6,000 73,000 20,000 27,000 34,000 6,000 6,100] 183] 152 | 230 [13,000 13,100] 578] 515 | 633 [20,000 20,100] 980] 918 | 1,035] 27,000 27,100] 1,383] 1,320 | 1,438] 34,000 34,100] 1,785] 1,723 | 1,840 6,100 6,200] 188] 156 | 236 | 13,100 13,200] 584] 521 | 639 |20,100 20,200] 986 | 924 | 1,041] 27,100 27,200] 1,389] 1,326 | 1,444] 34,100 34,200] 1,791] 1,729 | 1,846 6,200 6,300] 193] 160 | 242 |13,200 13,300] 589| 527 | 644 }20,200 20,300} 992 | 929 | 1,047] 27,200 27,300] 1,394] 1,332 | 1,449] 34,200 34,300] 1,797] 1,734 | 1,852 6,300 6,400] 198] 164 | 248 |13,300 13,400] 595| 533 | 650 }20,300 20,400] 998 | 935 | 1,053] 27,300 27,400] 1,400] 1,338 | 1,455] 34,300 34,400] 1,803] 1,740 | 1,858 6,400 6,500] 203] 168 | 253 | 13,400 13,500] 601] 538 | 656 |20,400 20,500] 1,003] 941 | 1,058] 27,400 27,500] 1,406] 1,343 | 1,461] 34,400 34,500] 1,808] 1,746 | 1,863 6,500 6,600] 208] 172 | 259 | 13,500 13,600] 607] 544 | 662 |20,500 20,600] 1,009] 947 | 1,064] 27,500 27,600] 1,412] 1,349 | 1,467] 34,500 34,600] 1,814] 1,752 | 1,869 6,600 6,700] 213| 176 | 265 | 13,600 13,700] 612] 550 | 667 |20,600 20,700] 1,015] 952 | 1,070} 27,600 27,700] 1,417] 1,355 | 1,472] 34,600 34,700] 1,820] 1,757 | 1,875 6,700 6,800] 218] 180 | 271 |13,700 13,800] 618] 556 | 673 }20,700 20,800} 1,021} 958 | 1,076] 27,700 27,800] 1,423] 1,361 | 1,478] 34,700 34,800] 1,826] 1,763 | 1,881 6,800 6,900] 223] 184 | 276 |13,800 13,900] 624| 561 | 679 }20,800 20,900] 1,026] 964 | 1,081] 27,800 27,900] 1,429] 1,366 | 1,484] 34,800 34,900] 1,831] 1,769 | 1,886 6,900 7,000] 228| 188 | 282 |13,900 14,000] 630| 567 | 685 [20,900 21,000] 1,032| 970 _| 1,087] 27,900 28,000] 1,435] 1,372 | 1,490] 34,900 35,000] 1,837| 1,775 | 1,892

Page 53

This amount should be placed on Line 16, Form 500 or Line 4, Form 500EZ GEORGIA INCOME TAX

Line 15c, Form 500 Line 15, Form 500 Line 15c, Form 500 Line 15c, Form 500 Married or Married or Line 3, Form or Line 3, Form Line 3, Form S00EZ Filing 500EZ ‘S00EZ Jointly or| Married

or Line 3, Form 500EZ Married

Filing At | ButLess

‘Sopa- Single Single Single ratoly | Least | Than T single

At | ButLess Least | Than

at | ButLess Least Than

At | But Less Least | Than

Married

Married Filing Sepa- rately

Line 15¢, Form 500 or Line 3, Form 500EZ

At Least

But Less Than

Single

ing Jointly or Head of House- hold

Married Filing Sepa- rately

35,000 42,000 ‘49,000 56,000

63,000

35,000 35,100} 1,843} 1,780] 1,898] 42,000 42,100] 2,245) 2,183] 2,300] 49,000 49,100} 2,648) 2,585) 2,703] 56,000 56,100} 3,050 35,100 35,200] 1,849} 1,786] 1,904] 42,100 42,200] 2,251] 2,189} 2,306] 49,100 49,200] 2,654) 2,591) 2,709] 56,100 56,200] 3,056 35,200 35,300] 1,854} 1,792] 1,909] 42,200 42,300] 2,257| 2,194} 2,312] 49,200 49,300] 2,659] 2,597) 2,714] 56,200 56,300] 3,062 35,300 35,400] 1,860} 1,798] 1,915] 42,300 42,400] 2,263] 2,200} 2,318] 49,300 49,400] 2,665] 2,603) 2,720] 56,300 56,400] 3,068 35,400 35,500] 1,866} 1,803) 1,921] 42,400 42,500] 2,268] 2,206} 2,323] 49,400 49,500] 2,671] 2,608) 2,726] 56,400 56,500] 3,073 35,500 35,600] 1,872} 1,809] 1,927] 42,500 42,600] 2,274] 2,212) 2,329] 49,500 49,600] 2,677) 2,614) 2,732] 56,500 56,600] 3,079 35,600 35,700} 1,877} 1,815] 1,932] 42,600 42,700] 2,280] 2,217} 2,335] 49,600 49,700) 2,682) 2,620) 2,737] 56,600 56,700] 3,085 35,700 35,800] 1,883} 1,821] 1,938] 42,700 42,800] 2,286] 2,223) 2,341] 49,700 49,800) 2,688) 2,626) 2,743] 56,700 56,800} 3,091 35,800 35,900] 1,889} 1,826] 1,944] 42,800 42,900] 2,291] 2,229) 2,346] 49,800 49,900] 2,694) 2,631) 2,749] 56,800 56,900] 3,096 35,900 36,000} 1,895} 1,832] 1,950] 42,900 43,000] 2,297| 2,235} 2,352] 49,900 50,000} 2,700} 2,637) 2,755} 56,900 57,000} 3,102

3,105) 3,111 3,117] 3,123} 3,128] 3,134 3,140 3,146) 3,151 3,157

63,000 63,100 63,200 63,300 63,400 63,500 63,600 63,700 63,800 63,900

63,100} 63,200} 63,300} 63,400} 63,500} 63,600} 63,700} 63,800} 63,900} 64,000}

3,453, 3,459, 3,464 3,470 3,476 3,482 3,487, 3,493, 3,499 3,505,

3,390, 3,396, 3,402 3,408, 3,413, 3,419 3,425 3,431 3,436 3,442

3,508) 3,514) 3,519) 3,525) 3,531 3,537] 3,542) 3,548) 3,554) 3,560)

36,000. 43,000 50,000 57,000

64,000

36,000 36,100} 1,900} 1,838] 1,955] 43,000 43,100] 2,303) 2,240} 2,358] 50,000 50,100} 2,705) 2,643) 2,760] 57,000 57,100} 3,108 36,100 36,200] 1,906} 1,844) 1,961] 43,100 43,200] 2,309] 2,246} 2,364] 50,100 50,200} 2,711] 2,649) 2,766] 57,100 57,200] 3,114 36,200 36,300] 1,912} 1,849] 1,967] 43,200 43,300] 2,314] 2,252} 2,369] 50,200 50,300] 2,717) 2,654) 2,772] 57,200 57,300] 3,119 36,300 36,400] 1,918} 1,855) 1,973] 43,300 43,400] 2,320] 2,258} 2,375] 50,300 50,400} 2,723) 2,660) 2,778] 57,300 57,400] 3,125 36,400 36,500] 1,923} 1,861] 1,978] 43,400 43,500] 2,326] 2,263} 2,381] 50,400 50,500} 2,728) 2,666) 2,783] 57,400 57,500] 3,131 36,500 36,600] 1,929} 1,867| 1,984] 43,500 43,600] 2,332) 2,269} 2,387] 50,500 50,600} 2,734) 2,672) 2,789] 57,500 57,600) 3,137 36,600 36,700} 1,935} 1,872] 1,990] 43,600 43,700] 2,337| 2,275} 2,392] 50,600 50,700} 2,740) 2,677) 2,795] 57,600 57,700] 3,142 36,700 36,800] 1,941} 1,878] 1,996] 43,700 43,800] 2,343] 2,281} 2,398] 50,700 50,800} 2,746] 2,683) 2,801] 57,700 57,800] 3,148 36,800 36,900] 1,946} 1,884] 2,001] 43,800 43,900] 2,349] 2,286] 2,404] 50,800 50,900} 2,751] 2,689) 2,806] 57,800 57,900] 3,154 36,900 37,000} 1,952} 1,890} 2,007] 43,900 44,000] 2,355} 2,292} 2,410] 50,900 51,000} 2,757} 2,695) 2,812} 57,900 58,000} 3,160

3,163 3,169 3,174) 3,180) 3,186 3,192 3,197 3,203} 3,209) 3,215

64,000 64,100 64,200 64,300 64,400 64,500 64,600 64,700 64,800 64,900

64,100} 64,200} 64,300} 64,400} 64,500} 64,600} 64,700} 64,800} 64,900} 65,000}

3,510, 3,516, 3,522 3,528, 3,533, 3,539, 3,545, 3,551 3,556, 3,562,

3,448, 3,454, 3,459 3,465 3,471 3,477 3,482 3,488, 3,494, 3,500,

3,565) 3,571 3,577 3,583) 3,588) 3,594) 3,600) 3,606) 3,611 3,617]

37,000 44,000 51,000 58,000

65,000

37,000 37,100} 1,958} 1,895] 2,013] 44,000 44,100] 2,360] 2,298} 2,415] 51,000 51,100] 2,763) 2,700) 2,818] 58,000 58,100] 3,165 37,100 37,200] 1,964} 1,901] 2,019] 44,100 44,200] 2,366] 2,304} 2,421] 51,100 51,200) 2,769} 2,706) 2,824] 58,100 58,200} 3,171 37,200 37,300] 1,969} 1,907] 2,024] 44,200 44,300] 2,372] 2,309} 2,427] 51,200 51,300) 2,774) 2,712) 2,829] 58,200 58,300] 3,177 37,300 37,400} 1,975} 1,913] 2,030] 44,300 44,400] 2,378] 2,315} 2,433] 51,300 51,400] 2,780} 2,718) 2,835] 58,300 58,400] 3,183 37,400 37,500} 1,981} 1,918] 2,036] 44,400 44,500] 2,383) 2,321} 2,438] 51,400 51,500} 2,786] 2,723) 2,841] 58,400 58,500] 3,188 37,500 37,600} 1,987} 1,924] 2,042] 44,500 44,600] 2,389) 2,327} 2,444] 51,500 51,600} 2,792) 2,729) 2,847] 58,500 58,600} 3,194 37,600 37,700} 1,992} 1,930] 2,047] 44,600 44,700] 2,395] 2,332} 2,450] 51,600 51,700] 2,797) 2,735) 2,852] 58,600 58,700] 3,200 37,700 37,800] 1,998} 1,936] 2,053] 44,700 44,800] 2,401] 2,338] 2,456] 51,700 51,800] 2,803) 2,741) 2,858] 58,700 58,800] 3,206 37,800 37,900} 2,004} 1,941] 2,059] 44,800 44,900] 2,406] 2,344} 2,461] 51,800 51,900} 2,809} 2,746) 2,864] 58,800 58,900} 3,211 37,900 38,000} 2,010} 1,947} 2,065] 44,900 45,000] 2,412] 2,350} 2,467] 51,900 52,000} 2,815} 2,752) 2,870} 58,900 59,000} 3,217

3,220 3,226 3,232| 3,238 3,243) 3,249 3,255) 3,261 3,266 3,272

65,000 65,100 65,200 65,300 65,400 65,500 65,600 65,700 65,800 65,900

65,100} 65,200} 65,300} 65,400} 65,500} 65,600} 65,700} 65,800} 65,900} 66,000}

3,568, 3,574, 3,579) 3,585) 3,591 3,597, 3,602, 3,608, 3,614 3,620,

3,505, 3,511 3,517, 3,523, 3,528, 3,534, 3,540, 3,546 3,551 3,557,

3,623) 3,629) 3,634) 3,640) 3,646) 3,652) 3,657] 3,663) 3,669) 3,675)

38,000 45,000 52,000 59,000

66,000

38,000 38,100] 2,015} 1,953] 2,070] 45,000 45,100] 2,418] 2,355} 2,473] 52,000 52,100} 2,820) 2,758) 2,875} 59,000 59,100} 3,223 38,100 38,200] 2,021} 1,959] 2,076] 45,100 45,200] 2,424] 2,361} 2,479] 52,100 52,200) 2,826] 2,764) 2,881] 59,100 59,200] 3,229 38,200 38,300] 2,027} 1,964] 2,082] 45,200 45,300] 2,429] 2,367} 2,484] 52,200 52,300] 2,832] 2,769) 2,887] 59,200 59,300] 3,234 38,300 38,400] 2,033} 1,970] 2,088] 45,300 45,400] 2,435] 2,373} 2,490] 52,300 52,400] 2,838] 2,775) 2,893] 59,300 59,400] 3,240 38,400 38,500] 2,038} 1,976] 2,093] 45,400 45,500] 2,441] 2,378] 2,496] 52,400 52,500] 2,843) 2,781) 2,898] 59,400 59,500] 3,246 38,500 38,600] 2,044} 1,982} 2,099] 45,500 45,600] 2,447| 2,384] 2,502] 52,500 52,600} 2,849) 2,787) 2,904] 59,500 59,600} 3,252 38,600 38,700] 2,050} 1,987] 2,105] 45,600 45,700] 2,452] 2,390} 2,507] 52,600 52,700} 2,855] 2,792) 2,910] 59,600 59,700] 3,257 38,700 38,800] 2,056} 1,993) 2,111] 45,700 45,800] 2,458] 2,396} 2,513] 52,700 52,800] 2,861] 2,798) 2,916] 59,700 59,800] 3,263 38,800 38,900] 2,061} 1,999] 2,116] 45,800 45,900] 2,464] 2,401} 2,519] 52,800 52,900] 2,866] 2,804) 2,921] 59,800 59,900] 3,269 38,900 39,000} 2,067} 2,005] 2,122] 45,900 46,000] 2,470] 2,407} 2,525] 52,900 53,000} 2,872} 2,810) 2,927] 59,900 60,000} 3,275

3,278 3,284 3,289) 3,295) 3,301 3,307 3,312 3,318] 3,324) 3,330

66,000 66,100 66,200 66,300 66,400 66,500 66,600 66,700 66,800 66,900

66,100} 66,200} 66,300} 66,400} 66,500} 66,600} 66,700} 66,800} 66,900} 67,000}

3,625, 3,631 3,637, 3,643, 3,648, 3,654, 3,660, 3,666 3,671 3,677

3,563, 3,569, 3,574 3,580, 3,586, 3,592, 3,597, 3,603, 3,609) 3,615,

3,680) 3,686) 3,692) 3,698) 3,703) 3,709) 3,715) 3,721 3,726) 3,732)

39,000) 46,000 53,000 60,000

67,000

39,000 39,100} 2,073} 2,010} 2,128] 46,000 46,100] 2,475] 2,413] 2,530] 53,000 53,100] 2,878} 2,815) 2,933] 60,000 60,100} 3,280 39,100 39,200] 2,079} 2,016] 2,134] 46,100 46,200] 2,481] 2,419} 2,536] 53,100 53,200] 2,884] 2,821) 2,939] 60,100 60,200] 3,286 39,200 39,300] 2,084} 2,022) 2,139] 46,200 46,300] 2,487| 2,424) 2,542] 53,200 53,300] 2,889] 2,827) 2,944] 60,200 60,300] 3,292 39,300 39,400] 2,090} 2,028] 2,145] 46,300 46,400] 2,493] 2,430} 2,548] 53,300 53,400] 2,895] 2,833) 2,950] 60,300 60,400] 3,298 39,400 39,500] 2,096} 2,033) 2,151] 46,400 46,500] 2,498] 2,436] 2,553] 53,400 53,500} 2,901] 2,838) 2,956] 60,400 60,500] 3,303 39,500 39,600] 2,102} 2,039] 2,157] 46,500 46,600] 2,504] 2,442) 2,559] 53,500 53,600] 2,907) 2,844) 2,962] 60,500 60,600] 3,309 39,600 39,700] 2,107} 2,045] 2,162] 46,600 46,700] 2,510] 2,447} 2,565] 53,600 53,700] 2,912) 2,850) 2,967] 60,600 60,700] 3,315 39,700 39,800] 2,113} 2,051] 2,168] 46,700 46,800] 2,516) 2,453} 2,571] 53,700 53,800) 2,918) 2,856) 2,973] 60,700 60,800} 3,321 39,800 39,900] 2,119} 2,056] 2,174] 46,800 46,900] 2,521] 2,459} 2,576] 53,800 53,900} 2,924) 2,861) 2,979] 60,800 60,900] 3,326 39,900 40,000} 2,125} 2,062} 2,180] 46,900 47,000] 2,527| 2,465} 2,582] 53,900 54,000} 2,930} 2,867] 2,985} 60,900 61,000} 3,332

3,335) 3,341 3,347| 3,353] 3,358) 3,364 3,370 3,376| 3,381 3,387

67,000 67,100 67,200 67,300 67,400 67,500 67,600 67,700 67,800 67,900

67,100} 67,200} 67,300} 67,400} 67,500} 67,600} 67,700} 67,800} 67,900} 68,000}

3,683, 3,689, 3,694, 3,700, 3,706 3,712 3,717 3,723, 3,729 3,735,

3,620, 3,626 3,632 3,638, 3,643, 3,649, 3,655, 3,661 3,666 3,672

3,738) 3,744) 3,749) 3,755) 3,761 3,767) 3,772 3,778) 3,784) 3,790)

40,000 47,000 54,000 61,000

68,000

40,000 40,100} 2,130) 2,068} 2,185} 47,000 47,100] 2,533} 2,470] 2,588] 54,000 54,100] 2,935) 2,873) 2,990] 61,000 61,100} 3,338 40,100 40,200} 2,136) 2,074} 2,191] 47,100 47,200] 2,539] 2,476] 2,594] 54,100 54,200] 2,941) 2,879) 2,996] 61,100 61,200] 3,344) 40,200 40,300] 2,142) 2,079} 2,197] 47,200 47,300] 2,544] 2,482] 2,599] 54,200 54,300] 2,947) 2,884) 3,002] 61,200 61,300] 3,349) 40,300 40,400] 2,148) 2,085} 2,203] 47,300 47,400] 2,550} 2,488] 2,605} 54,300 54,400] 2,953) 2,890) 3,008] 61,300 61,400] 3,355) 40,400 40,500] 2,153} 2,091] 2,208] 47,400 47,500] 2,556] 2,493} 2,611] 54,400 54,500] 2,958) 2,896) 3,013] 61,400 61,500] 3,361 40,500 40,600} 2,159} 2,097| 2,214] 47,500 47,600] 2,562) 2,499} 2,617] 54,500 54,600} 2,964) 2,902) 3,019] 61,500 61,600] 3,367 40,600 40,700} 2,165) 2,102} 2,220] 47,600 47,700] 2,567] 2,505| 2,622} 54,600 54,700] 2,970) 2,907) 3,025] 61,600 61,700] 3,372) 40,700 40,800] 2,171) 2,108} 2,226] 47,700 47,800] 2,573] 2,511] 2,628] 54,700 54,800] 2,976) 2,913) 3,031] 61,700 61,800] 3,378 40,800 40,900] 2,176) 2,114} 2,231] 47,800 47,900] 2,579] 2,516] 2,634] 54,800 54,900] 2,981) 2,919) 3,036] 61,800 61,900] 3,384| 40,900 41,000} 2,182} 2,120} 2,237] 47,900 48,000} 2,585} 2,522] 2,640} 54,900 55,000} 2,987) 2,925] 3,042] 61,900 62,000} 3,390

3,393 3,399 3,404) 3,410) 3,416) 3,422 3,427 3,433} 3,439) 3,445

68,000 68,100 68,200 68,300 68,400 68,500 68,600 68,700 68,800 68,900

68,100} 68,200} 68,300} 68,400} 68,500} 68,600} 68,700} 68,800} 68,900} 69,000}

3,740, 3,746, 3,752 3,758, 3,763, 3,769, 3,775, 3,781 3,786 3,792,

3,678 3,684, 3,689 3,695, 3,701 3,707, 3,712 3,718 3,724 3,730,

3,795) 3,801 3,807] 3,813) 3,818) 3,824) 3,830) 3,836) 3,841 3,847)

‘41,000 48,000 55,000 62,000

69,000

41,000 41,100] 2,188) 2,125} 2,243] 48,000 48,100] 2,590} 2,528] 2,645} 55,000 55,100] 2,993) 2,930) 3,048] 62,000 62,100] 3,395) 41,100 41,200] 2,194] 2,131] 2,249] 48,100 48,200] 2,596} 2,534] 2,651] 55,100 55,200] 2,999) 2,936] 3,054] 62,100 62,200} 3,401 41,200 41,300] 2,199] 2,137] 2,254] 48,200 48,300] 2,602] 2,539] 2,657] 55,200 55,300] 3,004) 2,942) 3,059] 62,200 62,300] 3,407] 41,300 41,400] 2,205) 2,143] 2,260] 48,300 48,400] 2,608] 2,545] 2,663] 55,300 55,400] 3,010) 2,948) 3,065] 62,300 62,400] 3,413} 41,400 41,500] 2,211} 2,148] 2,266] 48,400 48,500] 2,613) 2,551} 2,668] 55,400 55,500] 3,016] 2,953) 3,071] 62,400 62,500] 3,418 41,500 41,600] 2,217} 2,154) 2,272] 48,500 48,600] 2,619) 2,557} 2,674] 55,500 55,600} 3,022) 2,959) 3,077] 62,500 62,600] 3,424 41,600 41,700] 2,222) 2,160} 2,277] 48,600 48,700] 2,625] 2,562| 2,680] 55,600 55,700] 3,027) 2,965) 3,082] 62,600 62,700] 3,430) 41,700 41,800] 2,228) 2,166} 2,283] 48,700 48,800] 2,631] 2,568] 2,686] 55,700 55,800] 3,033) 2,971) 3,088] 62,700 62,800] 3,436 41,800 41,900] 2,234) 2,171} 2,289] 48,800 48,900] 2,636] 2,574] 2,691] 55,800 55,900} 3,039) 2,976] 3,094] 62,800 62,900] 3,441 41,900 42,000] 2,240} 2,177} 2,295] 48,900 49,000} 2,642} 2,580] 2,697] 55,900 56,000} 3,045) 2,982} 3,100] 62,900 63,000] 3,447

3,450 3,456 3,462 3,468) 3,473} 3,479 3,485 3,491 3,496 3,502

69,000 69,100 69,200 69,300 69,400 69,500 69,600 69,700 69,800 69,900

69,100} 69,200} 69,300} 69,400} 69,500} 69,600} 69,700} 69,800} 69,900} 70,000}

3,798, 3,804, 3,809) 3,815 3,821 3,827, 3,832, 3,838, 3,844, 3,850,

3,735, 3,741 3,747 3,753, 3,758, 3,764, 3,770, 3,776 3,781 3,787,

3,853} 3,859) 3,864) 3,870) 3,876) 3,882) 3,887) 3,893) 3,899) 3,905)

Page 54

This amount should be placed on Line 16, Form 500 or Line 4, Form 500EZ

GEORGIA INCOME TAX

Line 15c, Form 500 or Line 3, Form 800EZ

At Least

But Less Than

Single

Married Filing Jointly or Head of House- hold

Married Filing Sopa- rately

Line 15¢, Form 500 fr Line 3, Form S00EZ

at Least

But Less Than

Single

Married Filing Jointly or Head of House- hold.

Married Filing ‘Sepa- rately

Line 15c, Form 500 or Line 3, Form S00EZ

At Least

But Less Than

Single

Married Filing Jointly or Head of House- hold

Married Filing Sopa- rately

Line 15c, Form 500 or Line 3, Form 800EZ

At Least

But Less Than

Single

Married Filing Jointly or Head of House- hold

Married Filing Sopa- rately

15c, Form 500

or Line 3, Form 500EZ

At Least

But Less Than

Single

Married Filing Jointly or Head of House- hold

Married Filing Sopa- rately

70,000

77,000

84,000

91,000

98,000

70,000 70,100 70,200 70,300 70,400 70,500 70,600 70,700 70,800 70,900

70,100 70,200 70,300 70,400 70,500 70,600 70,700 70,800 70,900 71,000

3,855, 3,861 3,867 3,873 3,878 3,884 3,890 3,896 3,901 3,907

3,793, 3,799, 3,804, 3,810, 3,816, 3,822, 3,827, 3,833, 3,839, 3,845,

3,910) 3,916 3,922 3,928) 3,933) 3,939) 3,945, 3,951 3,956) 3,962,

77,000 77,100 77,200 77,300 77,400 77,500 77,600 77,700 77,800 77,900

77,100} 77,200} 77,300} 77,400 77,500} 77,600 77,700 77,800} 77,900} 78,000}

4,258 4,264 4,269 4,275 4,281 4,287 4,292 4,298 4,304 4,310

4,195) 4,201 4,207 4,213) 4,218) 4,224 4,230) 4,236| 4,241 4,247

4,313 4,319 4,324 4,330 4,336 4,342 4,347 4,353 4,359 4,365

84,000 84,100 84,200 84,300 84,400 84,500 84,600 84,700 84,800 84,900

84,100} 84,200} 84,300} 84,400} 84,500} 84,600} 84,700} 84,800} 84,900} 85,000}

4,660) 4,666) 4,672 4,678) 4,683) 4,689) 4,695) 4,701 4,706| 4,712

4,598 4,604 4,609 4,615 4,621 4,627 4,632 4,638 4,644 4,650

4,715 4,721 4,727 4,733 4,738 4,744 4,750 4,756 4,761 4,767

91,000 91,100 91,200 91,300 91,400 91,500 91,600 91,700 91,800 91,900

91,100) 91,200) 91,300) 91,400) 91,500) 91,600) 91,700) 91,800) 91,900) 92,000)

5,063 5,069 5,074 5,080 5,086 5,092 5,097 5,103 5,109 5,115

5,000, 5,006, 5,012, 5,018, 5,023, 5,029, 5,035, 5,041 5,046, 5,052,

5,118 5,124, 5,129) 5,135) 5,141 5,147, 5,152 5,158) 5,164, 5,170)

98,000 98,100 98,200 98,300 98,400 98,500 98,600 98,700 98,800 98,900

98,100} 98,200} 98,300} 98,400} 98,500} 98,600} 98,700} 98,800} 98,900} 99,000}

5,465 5,471 5,477 5,483 5,488 5,494 5,500 5,506 5,511 5,517,

5,403 | 5,409, 5,414, 5,420, 5,426, 5,432, 5,437, 5,443, 5,449, 5,455)

5,520 5,526 5,532, 5,538) 5,543, 5,549) 5,555) 5,561 5,566 5,572)

71,000

78,000

85,000

92,000

99,000

71,000 71,100 71,200 71,300 71,400 71,500 71,600 71,700 71,800 71,900

71,100 71,200 71,300 71,400 71,500 71,600 71,700 71,800 71,900 72,000

3,913 3,919 3,924 3,930 3,936 3,942 3,947 3,953 3,959 3,965

3,850, 3,856, 3,862, 3,868 | 3,873, 3,879, 3,885, 3,891 3,896, 3,902,

3,968) 3,974, 3,979) 3,985) 3,991 3,997, 4,002 4,008} 4,014] 4,020}

78,000 78,100 78,200 78,300 78,400 78,500 78,600 78,700 78,800 78,900

78,100} 78,200} 78,300} 78,400} 78,500} 78,600} 78,700} 78,800} 78,900} 79,000}

4,315 4,321 4,327 4,333 4,338 4,344 4,350 4,356 4,361 4,367

4,253 4,259 4,264 4,270 4,276 4,282 4,287 4,293 4,299 4,305

4,370 4,376 4,382 4,388 4,393 4,399 4,405 4,411 4,416 4,422

85,000 85,100 85,200 85,300 85,400 85,500 85,600 85,700 85,800 85,900

85,100} 85,200} 85,300} 85,400} 85,500} 85,600} 85,700} 85,800} 85,900} 86,000}

4,718) 4,724) 4,729 4,735) 4,741 4,747 4,752 4,758 | 4,764| 4,770!

4,655 4,661 4,667 4,673 4,678 4,684 4,690 4,696 4,701 4,707

4,773 4,779 4,784 4,790 4,796 4,802 4,807 4,813 4,819 4,825

92,000 92,100 92,200 92,300 92,400 92,500 92,600 92,700 92,800 92,900

92,100) 92,200) 92,300) 92,400) 92,500) 92,600) 92,700) 92,800 92,900) 93,000)

5,120 5,126 5,132 5,138 5,143 5,149 5,155 5,161 5,166 5,172

5,058 | 5,064, 5,069, 5,075, 5,081 5,087, 5,092, 5,098 | 5,104, 5,110)

5,175) 5,181 5,187, 5,193) 5,198) 5,204, 5,210 5,216 5,221 5,227)

99,000 99,100 99,200 99,300 99,400 99,500 99,600 99,700 99,800 99,900

99,100} 99,200} 99,300} 99,400} 99,500} 99,600} 99,700} 99,800} 99,900} 100,000}

5,523 5,529 5,534 5,540 5,546 5,552 5,557 5,563 5,569 5,575

5,460, 5,466, 5,472, 5,478, 5,483, 5,489, 5,495, 5,501 5,506, 5,512,

5,578 5,584) 5,589) 5,595) 5,601

72,000

79,000

86,000

93,000

72,000 72,100 72,200 72,300 72,400 72,500 72,600 72,700 72,800 72,900

72,100 72,200 72,300 72,400 72,500 72,600 72,700 72,800 72,900 73,000

3,970 3,976 3,982 3,988, 3,993 3,999 4,005 4,011 4,016 4,022

3,908 | 3,914, 3,919, 3,925, 3,931 3,937, 3,942, 3,948, 3,954, 3,960)

4,025 4,031 4,037 4,043 4,048 4,054 4,060 4,066 4,071 4,077

79,000 79,100 79,200 79,300 79,400 79,500 79,600 79,700 79,800 79,900

79,100} 79,200} 79,300} 79,400} 79,500} 79,600} 79,700} 79,800} 79,900} 80,000}

4,373 4,379 4,384 4,390 4,396 4,402 4,407 4,413 4,419 4,425

4,310 4,316 4,322 4,328 4,333 4,339 4,345 4,351 4,356 4,362

4,428 4,434 4,439 4,445 4,451 4,457 4,462 4,468 4,474 4,480

86,000 86,100 86,200 86,300 86,400 86,500 86,600 86,700 86,800 86,900

86,100} 86,200} 86,300} 86,400} 86,500} 86,600} 86,700} 86,800} 86,900} 87,000}

4,775) 4,781 4,787 4,793) 4,798 | 4,804 4,810) 4,816) 4,821 4,827

4713 4,719 4,724 4,730 4,736 4,742 4,747 4,753 4,759 4,765

4,830 4,836 4,842 4,848 4,853 4,859 4,865 4,871 4,876 4,882

93,000 93,100 93,200 93,300 93,400 93,500 93,600 93,700 93,800 93,900

93,100) 93,200) 93,300) 93,400) 93,500) 93,600 93,700) 93,800) 93,900) 94,000;

5,178 5,184 5,189 5,195, 5,201 5,207 5,212 5,218 5,224 5,230

5,115) 5,121 5,127, 5,133) 5,138, 5,144, 5,150, 5,156, 5,161 5,167)

5,233) 5,239) 5,244, 5,250) 5,256 5,262 5,267, 5,273, 5,279) 5,285)

‘$100,000 or over

5,578

5,515

Plus 5.75% of the amount over 100,000

73,000

80,000

87,000

94,000

73,000 73,100 73,200 73,300 73,400 73,500 73,600 73,700 73,800 73,900

73,100 73,200 73,300 73,400 73,500 73,600 73,700 73,800 73,900 74,000

4,028 4,034 4,039 4,045 4,051 4,057 4,062 4,068 4,074 4,080

3,965) 3,971 3,977, 3,983, 3,988 | 3,994, 4,000 4,006 4,011 4,017

4,083} 4,089] 4,094| 4,100} 4,106} 4,112 4,117 4,123} 4,129] 4,135]

80,000 80,100 80,200 80,300 80,400 80,500 80,600 80,700 80,800 80,900

80,100} 80,200} 80,300} 80,400} 80,500} 80,600} 80,700} 80,800} 80,900} 81,000}

4,430 4,436 4,442 4,448 4,453 4,459 4,465 4,471 4,476 4,482

4,368 4,374 4,379 4,385 4,391 4,397 4,402 4,408 4,414 4,420

4,485 4,491 4,497 4,503 4,508 4,514 4,520 4,526 4,531 4,537

87,000 87,100 87,200 87,300 87,400 87,500 87,600 87,700 87,800 87,900

87,100} 87,200} 87,300} 87,400} 87,500} 87,600} 87,700} 87,800} 87,900} 88,000}

4833 4,839 4,844 4,850 4,856 4,862 4,867 4873 4,879 4,885

4,770 4,776 4,782 4,788 4,793 4,799 4,805 4,811 4,816 4,822

4,888 4,894 4,899 4,905 4,911 4,917 4,922 4,928 4,934 4,940

94,000 94,100 94,200 94,300 94,400 94,500 94,600 94,700 94,800 94,900

94,100) 94,200) 94,300) 94,400) 94,500) 94,600) 94,700) 94,800) 94,900) 95,000;

5,235 5,241 5,247 5,253 5,258 5,264 5,270 5,276 5,281 5,287

5,173) 5,179) 5,184, 5,190, 5,196, 5,202, 5,207, 5,213, 5,219) 5,225)

5,290 5,296

74,000

81,000

88,000

95,000

74,000 74,100 74,200 74,300 74,400 74,500 74,600 74,700 74,800 74,900

74,100 74,200 74,300 74,400 74,500 74,600 74,700 74,800 74,900 75,000

4,085 4,091 4,097 4,103 4,108 4,114 4,120 4,126 4,131 4,137

4,023 4,029 4,034 4,040 4,046 4,052 4,057 4,063 4,069 4,075

4,140] 4,146] 4,152 4,158} 4,163} 4,169] 4,175] 4,181 4,186] 4,192

81,000 81,100 81,200 81,300 81,400 81,500 81,600 81,700 81,800 81,900

81,100} 81,200 81,300 81,400 81,500 81,600 81,700 81,800} 81,900} 82,000}

4,488 4,494 4,499 4,505 4511 4,517 4,522 4,528 4,534 4,540

4425 4,431 4,437 4,443 4,448 4,454 4,460 4,466 4,471 4,477

4,543 4,549 4,554 4,560 4,566 4,572 4,577 4,583 4,589 4,595

88,000 88,100 88,200 88,300 88,400 88,500 88,600 88,700 88,800 88,900

88,100} 88,200} 88,300} 88,400} 88,500} 88,600} 88,700} 88,800} 88,900} 89,000}

4,890) 4,896 | 4,902 4,908 | 4,913) 4,919) 4,925) 4,931 4,936| 4,942

4,828 4,834 4,839 4,845 4,851 4,857 4,862 4,868 4,874 4,880

4,945 4,951 4,957 4,963 4,968 4,974 4,980 4,986 4,991 4,997

95,000 95,100 95,200 95,300 95,400 95,500 95,600 95,700 95,800 95,900

95,100) 95,200) 95,300) 95,400) 95,500) 95,600 95,700 95,800 95,900 96,000;

5,293 5,299 5,304 5,310 5,316 5,322 5,327 5,333 5,339 5,345

5,230) 5,236, 5,242, 5,248, 5,253, 5,259, 5,265, 5,271 5,276, 5,282,

5,365) 5,371 5,377 5,382, 5,388) 5,394, 5,400)

75,000

82,000

89,000

96,000

75,000 75,100 75,200 75,300 75,400 75,500 75,600 75,700 75,800 75,900

75,100 75,200 75,300 75,400 75,500 75,600 75,700 75,800 75,900 76,000

4,143 4,149 4,154 4,160 4,166 4,172 4,177 4,183 4,189 4,195

4,080 4,086 4,092 4,098 4,103 4,109 4,115 4,121 4,126 4,132

4,198 4,204 4,209 4,215 4,221 4,227 4,232 4,238 4,244 4,250

82,000 82,100 82,200 82,300 82,400 82,500 82,600 82,700 82,800 82,900

82,100} 82,200} 82,300} 82,400} 82,500} 82,600} 82,700} 82,800} 82,900} 83,000}

4,545 4,551 4,557 4,563 4,568 4,574 4,580 4,586 4,591 4,597

4483 4,489 4,494 4,500 4,506 4,512 4,517 4,523 4,529 4,535

4,600 4,606 4,612 4,618 4,623 4,629 4,635 4,641 4,646 4,652

89,000 89,100 89,200 89,300 89,400 89,500 89,600 89,700 89,800 89,900

89,100} 89,200} 89,300} 89,400} 89,500} 89,600} 89,700} 89,800} 89,900} 90,000}

4,948 | 4,954) 4,959) 4,965) 4,971 4,977 4,982 4,988 | 4,994) 5,000

4,885 4,891 4,897 4,903 4,908 4,914 4,920 4,926 4,931 4,937

5,003} 5,009) 5,014) 5,020} 5,026 5,032 5,037] 5,043} 5,049) 5,055}

96,000 96,100 96,200 96,300 96,400 96,500 96,600 96,700 96,800 96,900

96,100) 96,200) 96,300) 96,400) 96,500) 96,600; 96,700) 96,800) 96,900) 97,000

5,350 5,356 5,362 5,368 5,373 5,379 5,385 5,391 5,396 5,402

5,288 | 5,294, 5,299, 5,305, 5,311 5,317, 5,322, 5,328, 5,334, 5,340,

5,405) 5,411 5,417 5,423 5,428 5,434, 5,440 5,446 5,451 5,457)

76,000

83,000,

(90,000,

97,000,

76,000 76,100 76,200 76,300 76,400 76,500 76,600 76,700 76,800 76,900

76,100 76,200 76,300 76,400 76,500 76,600 76,700 76,800 76,900 77,000

4,200 4,206 4,212 4,218 4,223 4,229 4,235 4,241 4,246 4,252

4,138 4,144 4,149 4,155 4,161 4,167 4,172 4,178 4,184 4,190

4,255] 4,261 4,267 4,273] 4,278} 4,284| 4,290} 4,296 4,301 4,307

83,000 83,100 83,200 83,300 83,400 83,500 83,600 83,700 83,800 83,900

83,100} 83,200} 83,300} 83,400} 83,500} 83,600} 83,700} 83,800} 83,900} 84,000}

4,603 4,609 4,614 4,620 4,626 4,632 4,637 4,643 4,649 4,655

4,540) 4,546) 4,552 4,558 | 4,563) 4,569) 4,575) 4,581 4,586 | 4,592

4,658 4,664 4,669 4,675 4,681 4,687 4,692 4,698 4,704 4,710

90,000 90,100 90,200 90,300 90,400 90,500 90,600 90,700 90,800 90,900

90,100} 90,200} 90,300} 90,400} 90,500} 90,600} 90,700} 90,800} 90,900} 91,000}

5,005 5,011 5,017 5,023 5,028 5,034 5,040 5,046 5,051 5,057

4,943 4,949 4,954 4,960 4,966 4,972 4,977 4,983 4,989 4,995

5,060} 5,066 5,072 5,078| 5,083} 5,089} 5,095) 5,101 5,106 5,112

97,000 97,100 97,200 97,300 97,400 97,500 97,600 97,700 97,800 97,900

97,100) 97,200) 97,300) 97,400) 97,500) 97,600) 97,700) 97,800) 97,900) 98,000)

5,408 5,414 5,419 5,425 5,431 5,437 5,442 5,448 5,454 5,460

5,345, 5,351 5,357, 5,363, 5,368 | 5,374, 5,380, 5,386, 5,391 5,397)

5,463 5,469) 5,474, 5,480) 5,486 5,492 5,497, 5,503) 5,509) 5,515)

Page 55

STATE OF GEORGIA DEPARTMENT OF REVENUE TAXPAYER SERVICES DIVISION 1800 CENTURY BLVD. NE ATLANTA, GA 30345-3205