Georgia Form 500 (Rev. 06/22/22) Individual Income Tax Return Georgia Department of Revenue (Approved web version)

2022 Page 1

2. PART- YEAR RESIDENT TO 3. NONRESIDENT CITY (Please insert a space if the city has multiple names)

STATE ZIP CODE SPOUSE’S FIRST NAME MI 6a. Yourself 6b. Spouse 6c. 5. Enter Filing Status with appropriate letter (See IT-511 Tax Booklet)................................................................................... .... .... 5. rsion) Fiscal Year Ending 6. Number of exemptions (Check appropriate box(es) and enter total in 6c.) Filing Status Omit Lines 9 thru 14 and use Form 500 Schedule 3 if you are a part-year or nonresident filer. (Use 2nd address line for Apt, Suite or Building Number) LAST NAME

SUFFIX LAST NAME

SUFFIX ADDRESS (NUMBER AND STREET or P.O. BOX) CHECK IF ADDRESS HAS CHANGED

SPOUSE’S SOCIAL SECURITY NUMBER (COUNTRY IF FOREIGN) DEPARTMENT USE ONLY YOUR SOCIAL SECURITY NUMBER 1. 2. 3. 1. FULL- YEAR RESIDENT 4. Enter your Residency Status with the appropriate number .... ...................................................................................................... Residency Status 4. Fiscal Year Beginning YOUR FIRST NAME

MI 7a. 7a. Number of Dependents (Enter details on Line 7b., and DO NOT include yourself or your spouse)...................................... (For Name Change See IT-511 Tax Booklet) STATE ISSUED YOUR DRIVER’S LICENSE/STATE ID

This Page (1) is required for processing D. Head of Household or Qualifying Surviving Spouse A. Single B. Married filing joint C. Married filing separate (Spouse’s social security number must be entered above) PRINT COMPLETED FORM RESET Select

Pag e 2 Georgia Form500 Individual Income Tax Return Georgia Department of Revenue 2022

YOUR SOCIAL SECURITY NUMBER

7b. Dependents (If you have more than 4 dependents, attach a list of additional dependents) First Name, MI. Last Name Social Security Number Relationship to You 9. Adjustments from Form 500 Schedule 1 (See IT-511 Tax Booklet) ....................... 10. Georgia adjusted gross income (Net total of Line 8 and Line 9)............................. 8. Federal adjusted gross income (From Federal Form 1040)..................................... If amount on line 8, 9, 10, 13 or 15 is negative, use the minus sign (-). Example -3456.

8. (Do not use FEDERAL TAXABLE INCOME) If the amount on Line 8 is $40,000 or more, or your gross income is less than your W-2s you must include a copy of your Federal Form 1040 Pages 1, 2, and Schedule 1. 10. 9. INCOME COMPUTATIONS First Name, MI. Last Name Social Security Number Relationship to You First Name, MI. Last Name Social Security Number Relationship to You Social Security Number Relationship to You 11. Standard Deduction (Do not use FEDERAL STANDARD DEDUCTION).............. (See IT-511 Tax Booklet) c. Total Standard Deduction (Line 11a + Line 11b)................................................... b. Self: 65 or over? Blind? Spouse: 65 or over? Blind? Total x 1,300=......................... Use EITHER Line 11c OR Line 12c (Do not write on both lines) 11c. 11b. 11a. 12. Total Itemized Deductions used in computing Federal Taxable Income. If you use itemized deductions, you must include Federal Schedule A. a. Federal Itemized Deductions (Schedule A- Form 1040)............................... b. Less adjustments: (See IT-511 Tax Booklet) ................................................ 12a. 12c. 12b. c. Georgia Total Itemized Deductions..................................................................

13. Subtract either Line 11c or Line 12c from Line 10; enter balance.......................... 13.

First Name, MI. Last Name This Page (2) is required for processing RESET PAGE 2 PREVIOUS PAGE SELECT SELECT SELECT SELECT

Georgia Form500 Individual Income Tax Return Georgia Department of Revenue 2022 YOUR SOCIAL SECURITY NUMBER Pag e 3 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. 14a. Enter the number from Line 6c.

Multiply by $2,700 for filing status A or D 14a. 14b.

Enter the number from Line 7a. or multiply by $3,700 for filing status B or C Multiply by $3,000.......................................... 14b. 14c. 14c. Add Lines 14a. and 14b. Enter total ......................................................

16. 16. 17a. 17b. 17.

Low Income Credit 17c. ........................ 18. 19.

Other State(s) Tax Credit (Include a copy of the other state(s) return) ....... 18. C redits used from IND-CR Summary Worksheet ........................................ 19. 20. Total Credits Used from Schedule 2 Georgia Tax Credits (must be filed electronically) 20. 21. 21. 22. 22. Balance (Line 16 less Line 21) if zero or less than zero, enter

zero .......... Total Credits Used (sum of Lines 17-20) cannot ex ceed Line 16

........................

..... 15a. 15a. Income before GA NOL (Line 13 less Line 14c or Schedule 3, Line 14)..... 15b. 15b. Georgia NOL utilized (Cannot exceed Line 15a or the amount after applying the 80% limitation, see IT-511 Tax Booklet for more information).... 15c. 15c. Georgia Taxable Income (Line 15a less Line 15b)..................................... Tax (Use Tax Rate Schedule in the IT-511 Tax Booklet) ..........................

(INCOME STATEMENT A)

(INCOME STATEMENT B)

(INCOME STATEMENT C)

.

PLEASE COMPLETE INCOME STATEMENT DETAILS ON PAGE 4.

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1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE:

W -2 G2-A G2-LP G2-A W -2 G2-LP G2-A W -2 G2-LP 1099 G2-FL G2-RP 1099 G2-FL G2-RP 1099 G2-FL G2-RP 2. EMPLOYER/PAYER FEDERAL ID NUMBER (FEIN) SSN 2. EMPLOYER/PAYER FEDERAL ID NUMBER (FEIN) SSN 2. EMPLOYER/PAYER FEDERAL ID NUMBER (FEIN) SSN 3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID 4. GA WAGES / INCOME 4. GA WAGES / INCOME 4. GA WAGES / INCOME 5. GA TAX WITHHELD 5. GA TAX WITHHELD 5. GA TAX WITHHELD

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Georgia Form500 Individual Income Tax Return Georgia Department of Revenue YOUR SOCIAL SECURITY NUMBER 2022

Page 4 Estimated Tax paid for 2022 and Form IT-560 ......................................... 25. 23. 24. Other Georgia Income Tax Withheld

........................................................ 24. (Enter Tax Withheld Only and include W-2s and/or 1099s) 23. (Must include G2-A, G2-FL, G2-LP and/or G2-RP) Georgia Income Tax Withheld on Wages and 1099s ............................. 28. If Line 22 exceeds Line 27, subtract Line 27 from Line 22 and enter

balance due............................................................................................... 28. 26. overpayment .............................................................................................. 27. 29. If Line 27 exceeds Line 22, subtract Line 22 from Line 27 and enter 29. 30. Amount to be credited to 2023 ESTIMATED TAX ................................. 31. 32. Georgia Wildlife Conservation Fund (No gift of less than $1.00)............. Georgia Fund for Children and Elderly (No gift of less than $1.00)........ 33. Georgia Cancer Research Fund (No gift of less than $1.00) ................. 34. Georgia Land Conservation Program (No gift of less than $1.00)........... 35. 36 . Georgia National Guard Foundation (No gift of less than $1.00) ............. Dog & Cat Sterilization Fund (No gift of less than $1.00)....................... Saving the Cure Fund (No gift of less than $1.00)................................. (No gift of less than $1.00) Realizing Educational Achievement Can Happen (REACH) Program ............. 38. 37. 37. 31. 30. 32. 33. 34. 35. 36. 38. 25. 26. Schedule 2B Refundable Tax Credits.......................................................... (Cannot be claimed unless filed electronically) 27. Total prepayment credits (Add Lines 23, 24, 25 and 26)...........................

2. EMPLOYER/PAYER FEDERAL ID NUMBER (FEIN) SSN 2. EMPLOYER/PAYER FEDERAL ID NUMBER (FEIN) SSN 3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID (INCOME STATEMENT E)

2. EMPLOYER/PAYER FEDERAL ID NUMBER (FEIN) SSN 1. WITHHOLDING TYPE: 3. EMPLOYER/PAYER STATE WITHHOLDING ID 4. GA WAGES / INCOME 1. WITHHOLDING TYPE: 5. GA TAX WITHHELD 5. GA TAX WITHHELD 4. GA WAGES / INCOME 1. WITHHOLDING TYPE: 5. GA TAX WITHHELD 4. GA WAGES / INCOME

(INCOME STATEMENT F)

(INCOME STATEMENT D) W- 2 1099 G2-A G2-FL G2-LP G2-RP W- 2 1099 G2-A G2-FL G2-LP G2-RP W- 2 1099 G2-A G2-FL G2-LP G2-RP

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Georgia Form500 Individual Income Tax Return Georgia Department of Revenue 2022

YOUR SOCIAL SECURITY NUMBER Pag e 5 40.

Form 500 UET (Estimated tax penalty) 500 UET exception attached 40. 39. Public Safety Memorial Grant (No gift of less than $1.00)....................... 39.

Taxpayer’s Signature Spouse’s Signature (Check box if deceased) (Check box if deceased) By providing my e-mail address I am authorizing the Georgia Department of Revenue to electronically notify me at the below e-ma il address regarding any updates to my account(s). Taxpayer’s E-mail Address Preparer’s Firm Name Signature of Preparer Name of Preparer Other Than Taxpayer

I authorize DOR to discuss this return with the named preparer. Taxpayer’s Phone Number Spouse’s Signature Date Preparer’s Phone Number Preparer’s FEIN Preparer’s SSN/PTIN/SIDN Spouse’s Date of Death Taxpayer’s Date of Death Taxpayer’s Signature Date 44. Routing 43. (If you owe) Add Lines 28, 31 thru 42 .................................................... THIS IS YOUR REFUND......................................................................... Number Account

Type: Checking

Savings Number MAKE CHECK PAYABLE TO GEORGIA DEPARTMENT OF REVENUE, Mail To: GEORGIA DEPARTMENT OF REVENUE PROCESSING CENTER, PO BOX 740399 ATLANTA, GA 30374-0399

43. 44. (If you are due a refund) Subtract the sum of Lines 30 thru 42 from Line 29 If you do not enter Direct Deposit information or if you are a first time filer you will be issued a paper check. 44a. Direct Deposit (U.S. Accounts Only)

I/We declare under the penalties of perjury that I/we have examined this return (including accompanying schedules and statements) and to the best of my/our knowledge and belief, it is true, correct, and complete. If prepared by a person other than the taxpayer(s), this declaration is based on all information of which the preparer has knowledge.

41. Penalty: Late Payment and/or Late Filing.................................................... 41. 42. Interest ........................................................................................................ 42. Refund Due Mail To: GEORGIA DEPARTMENT OF REVENUE PROCESSING CENTER, PO BOX 740380 ATLANTA, GA 30374-0380 Mail pages 1-5 and any applicable schedules, forms, and documentation. DO NOT staple pages. This Page (5) is required for processing PRINT COMPLETED FORM RESET PAGE 5 PREVIOUS PAGE

Do: Use a payment voucher with a valid scanline. Only complete this voucher if you owe taxes. Complete the voucher in its entirety. Write your SSN or FEIN on your check or money order. Make check or money order payable to: Georgia Department of Revenue Remember if the due date falls on a weekend or holiday, the tax shall be due on the next day that is not a weekend or holiday. Mail your voucher and payment to the address listed below if your return was filed electronically. Processing Center Georgia Department of Revenue P O Box 740323 Atlanta, Georgia 30374-0323 Mail your return, payment voucher and payment to the address that appears on the return if filing a paper return. Do not: Georgi a Public Revenue Code Section 48-2-31 stipulates that taxes shall be paid in lawful money of the United States, free of any expense to the State of Georgia. 525-TV (Rev. 06/21/22) Individual and Fiduciary Payment Voucher Cut along dotted line Individual or Fiduciary Name and Address: Amended Return Paper Return Electronically Filed Type of Return: Taxpayer’s SSN or Fiduciary FEIN Spouse’s SSN (if joint or combined return) Tax Year Daytime Telephone Number Vendor Code 040 PLEASE DO NOT STAPLE. REMOVE ALL CHECK STUBS. PROCESSING CENTER GEORGIA DEPARTMENT OF REVENUE PO BOX 740323 ATLANTA GA30374-0323 Amount Paid $

Dos and Don’ts Checklist for the Individual/F iduciary (525-TV) Payment Voucher Payments can be made electronically on the Georgia Tax Center (GTC) gtc.dor.ga.gov/ . Mail this entire page. Staple your payment and voucher together. Print on both sides of the paper. Handwrite any information. [X] 09-INDIVIDUAL PREVIOUS PAGE

SCHEDULE 1 ADJUSTMENTS to INCOME BASED on GEORGIA LAW

YOUR SOCIAL SECURITY NUMBER Schedule 1 Page 1 Georgia Form500 (Rev. 06/22/22) Schedule 1 Adjustments to Income 2022 See IT-511 Tax Booklet

10.

2. 3. 1. 5. 4. 6. 14.

11. 9. 8. 13. ADDITIONS to INCOME 1. Interest on Non-Georgia Municipal and State Bonds ................................... 2. Lump Sum Distributions .........................................................................................

3. Reserved......................................................................................................................

6. Total Additions (Enter sum of Lines 1-5 here)..............................................

Other (Specify) 4. Net operating loss carryover deducted on Federal return....................................... 5. SUBTRACTION from INCOME (See IT-511 Tax Booklet) 7. Retirement Income Exclusion 8. Social Security Benefits (Taxable portion from Federal return).................... 9. Path2College 529 Plan ..............................................................................

10. Interest on United States Obligations (See IT-511 Tax Booklet )

11. Reserved ..................................................................................................

12. Other Adjustments (Specify) 13. Total Subtractions (Enter sum of Lines 7-12 here) ....................................... 14. Net Adjustments (Line 6 less Line 13). Enter Net Total here and on

Line 9 of Page 2 (+ or -) of Form 500 or 500 X ..........................................

Taxpayer Date of Birth: 7a. a. Retirement Income Exclusion - Complete Schedule 1, page 2. b. Military Retirement Income Exclusion (Must be under 62 years of age) - Complete Schedule 1, page 3. . 7b. 7c. Type of Disability:

c. Date of Disability:

12. Spouse Date of Birth: 7d. d. Retirement Income Exclusion - Complete Schedule 1, page 2. e. Military Retirement Income Exclusion (Must be under 62 years of age) - Complete Schedule 1, page 3. . 7e. 7f.

Type of Disability:

f. Date of Disability:

Required for Retirement Income Exclusion and Military Retirement Income Exclusion Required for Retirement Income Exclusion and Military Retirement Income Exclusion (Approved web version) RESET SCH 1 PG 1 RETURN TO PAGE 2

Schedule 1 Page 2 Georgia Form500 (Rev. 06/22/22) Schedule 1 Adjustments to Income 2022 YOUR SOCIAL SECURITY NUMBER *If age 62-64 or less than age 62 and permanently disabled enter $35,000, or if age 65 or older enter $65,000. (TAXPAYER) (SPOUSE) SCHEDULE 1 RETIREMENT INCOME EXCLUSION See IT-511 Tax Booklet 1. 2. Salary and wages...................................... 3. 4.

Other Earned Income (Losses)..................... Total Earned Income.................................... zero .......................................................... 6. Interest Income......................................... Maximum Earned Income........................... 7. Dividend Income ....................................... 9. 8. Alimony...................................................... 10. 5. Smaller of Line 3 or 4; if zero or less, enter

Capital Gains (Losses)............................... 11. Taxable IRA Distributions......................... 12. Other Income (Losses).............................. (See IT-511 Tax Booklet) Taxable Pensions ..................................... Income (Losses).....(See IT-511 Tax Booklet) 13. Rental, Royalty, Partnership, S Corp, etc. enter zero ................................................ 15. 14. Total of Lines 6 through 13; if zero or less, Add Lines 5 and 14 .................................... 16. Maximum Allowable Exclusion* .................. (Approved web version) 17. Smaller of Lines 15 and 16; enter here and on Form 500, Schedule 1, Lines 7a & d for Retire- ment Exclusion or Lines 7c & f for Retirement Exclusion for Disability............................ RESET SCH 1 PG 2 PREVIOUS PAGE 4000 4000

Schedule 1 Page 3 Georgia Form500 (Rev. 06/22/22) Schedule 1 Adjustments to Income 2022 YOUR SOCIAL SECURITY NUMBER SCHEDULE 1 MILITARY RETIREMENT INCOME EXCLUSION

See IT-511 Tax Booklet (Approved web version) (TAXPAYER) (SPOUSE)

See IT-511 Tax Booklet 1. Taxable Military Retirement from 1099-R 2. Base Military Exclusion............................. 3. Enter the smaller of Line 1 or Line 2 .........

If your taxable military retirement is less than 17,501 STOP HERE and enter line 3 on Schedule 1, Line 7b and 7e. 4. Taxable Georgia Salary and Wages...............

5. Other Earned Georgia Income.......................

6. Total Georgia Earned Income.........................

7. Total additional Military Exclusion allowed.......

8. Enter the smaller of Line 1 or Line 7. Enter this amount on Schedule 1, Lines 7b and e....... 1. Do you have any military retirement income? Do I Qualify for Military Retirement Exclusion? No. You do not qualify. Do not complete this page. Yes. You may qualify if you meet the age requirements. 2. Are you under the age of 62? No. You do not qualify. Do not complete this page. Yes. You qualify for Military Retirement Income Exclusion. Complete this page. If your Georgia earned income is less than 17,501 STOP HERE and enter line 3 on Schedule 1, Line 7b and 7e. 3. Include this page with your Form 500/500X, if applicable. RESET SCH 1 PG 3 PREVIOUS PAGE 17500 17500 35000 35000

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

1.

2. Credit Code ............................................................................................... 1.

3. COMPANY/INDIVIDUAL NAME

CREDIT CERTIFICATE # FEIN/SSN CREDIT GENERATED THIS TAX YEAR 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).........................

10. Enter the amount of the credit sold (only certain credits can be sold, see IT-511 Tax Booklet)........................................................................................ 12.

Potential carryover to next tax year (Line 9 less Lines 10 and 11).......................... 12. 9. 10. 11. 11. Credit used for this tax year....................................................................................

YOUR SOCIAL SECURITY NUMBER Georgia Form500 (Rev. 06/22/22) Schedule 2 Georgia Tax Credits 2022 SCHEDULE 2 GEORGIA TAX CREDIT USAGE AND CARRYOVER See IT-511 Tax Booklet Schedule 2 Page 1 (Approved software version) CREDITS MUST BE FILED ELECTRONICALLY CREDITS MUST BE FILED ELECTRONICALLY RESET SCH 2 PREVIOUS PAGE SEL

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

1.

2. Credit Code ............................................................................................... 1.

3. COMPANY/INDIVIDUAL NAME

CREDIT CERTIFICATE # FEIN/SSN CREDIT GENERATED THIS TAX YEAR 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

YOUR SOCIAL SECURITY NUMBER Georgia Form500 (Rev. 06/22/22) Schedule 2B Georgia Tax Credits 2022 SCHEDULE 2B REFUNDABLE TAX CREDITS See IT-511 Tax Booklet Schedule 2B Page 1 Note: A purchased Timber Tax Credit is not a refundable tax credit. Use Schedule 2 if the Timber Tax Credit was purchased.

9. Total available credit for this tax year (sum of Lines 2 through 8).........................

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

12.

Potential carryover to next tax year (Line 9 less Lines 10 and 11).......................... 12. 9. 10. 11. 11. Credit used for this tax year.................................................................................... (Approved software version) CREDITS MUST BE FILED ELECTRONICALLY CREDITS MUST BE FILED ELECTRONICALLY RESET SCH 2 PG2 PREVIOUS PAGE SE

YOUR SOCIAL SECURITY NUMBER Schedule 3 Page 1 Georgia Form500 (Rev. 06/22/22) Schedule 3 Part-Year Nonresident 2022 (Approved web version) DO NOT USE LINES 9 THRU 14 OF PAGES 2 AND 3 FORM 500 or 500X Income earned in another state as a Georgia resident is taxable but other state(s) 3. BUSINESS INCOME OR (LOSS) 3. BUSINESS INCOME OR (LOSS) 2. INTEREST AND DIVIDENDS 7. TOTAL ADJUSTMENTS FROM FORM 500, 2. INTEREST AND DIVIDENDS

(COLUMN B) 3. BUSINESS INCOME OR (LOSS) 1. WAGES, SALARIES, TIPS, etc 7. TOTAL ADJUSTMENTS FROM FORM 500, 6. TOTAL ADJUSTMENTS FROM FORM 1040 2. INTEREST AND DIVIDENDS 7. TOTAL ADJUSTMENTS FROM FORM 500, 6. TOTAL ADJUSTMENTS FROM FORM 1040 6. TOTAL ADJUSTMENTS FROM FORM 1040 5. TOTAL INCOME: TOTAL LINES 1 THRU 4 1. WAGES, SALARIES, TIPS, etc SCHEDULE 1 4. OTHER INCOME OR (LOSS) SCHEDULE 1 4. OTHER INCOME OR (LOSS) 5. TOTAL INCOME: TOTAL LINES 1 THRU 4 1. WAGES, SALARIES, TIPS, etc 4. OTHER INCOME OR (LOSS) FEDERAL INCOME AFTER GEORGIA ADJUSTMENT 5. TOTAL INCOME: TOTAL LINES 1 THRU 4 SCHEDULE 1 RESIDENTS AND NONRESIDENTS. SCHEDULE 3 COMPUTATION OF GEORGIA TAXABLE INCOME FOR ONLY PART-YEAR INCOME NOT TAXABLE TO GEORGIA GEORGIA INCOME

(COLUMN C) tax credit may apply. See IT-511 Tax Booklet. (COLUMN A) 8. ADJUSTED GROSS INCOME: LINE 5 PLUS OR MINUS LINES 6 AND 7 8. ADJUSTED GROSS INCOME: 8. ADJUSTED GROSS INCOME: LINE 5 PLUS OR MINUS LINES 6 AND 7 LINE 5 PLUS OR MINUS LINES 6 AND 7

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........................ 14.

13. Multiply Line 12 by Ratio on Line 9 and enter result............................................ 13. 11a. Enter the number on Line 6c from Form 500 or Form 500X multiply by $2,700 for filing status A or D or multiply by $3,700 for filing status B or C..................................... 11a. 11b. Enter the number on Line 7a from Form 500 or Form 500X multiply by $3,000 .. 11b. 12. Total Deductions and Exemptions: Add Lines 10a, 10b, 11a, and 11b ............ 12. 10b. Additional Standard Deduction Self: 65 or over? Blind? Spouse: 65 or over? Blind? Total X 1,300= 10b. 11. Personal Exemptions from Form 500 or Form 500X (See IT-511 Tax Booklet)

10a. Itemized or Standard Deduction (See IT-511 Tax Booklet)........................................................ 10a. 9. RATIO: Divide Line 8, Column C by Line 8, Column A enter percentage ....... 9. % Not to exceed 100% RESET SCH 3 RETURN TO PAGE 3

YOUR SOCIAL SECURITY NUMBER Form IND-CR 201 State of Georgia Individual Credit Form Georgia Department of Revenue 2022 1 Page (Rev. 06/22/22) (Approved web version) 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 years............................................................................. 1. – Include with Form 500 or 500X, if this schedule is applicable.– 2. 2. 3. 4. Potential carryover to next tax year (Line 1 plus Line 2 less Line 3) .............................. 4. 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 per residence................................................................................................................... 3.

Credit used this tax year (enter here and include on IND-CR Summary Worksheet Line 1)..........................................................................................................

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YOUR SOCIAL SECURITY NUMBER Form IND-CR 202 State of Georgia Individual Credit Form Georgia Department of Revenue 2022

1 Page (Rev. 06/22/22) (Approved web version) 30%

Child and Dependent Care Expense Credit - Tax Credit 202

O.C.G.A. § 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 Line 2)..................................................................................................................... 1. 2. 4. 3. – Include with Form 500 or 500X, if this schedule is applicable. – RESET INDCR02 PREVIOUS PAGE

YOUR SOCIAL SECURITY NUMBER Form IND-CR 203 State of Georgia Individual Credit Form Georgia Department of Revenue 2022

1 Page (Rev. 06/22/22) (Approved web version) Georgia National Guard/Air National Guard Credit - Tax Credit 203

O.C.G.A. § 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 years....................................................... 1. 2. Enter amount of qualified life insurance premiums ............................................ 2. 3.Credit used this tax year (enter here and include on IND-CR Summary Worksheet Line 3)...................................................................................... 3. 4. Carryover to next tax year (Line 1 plus Line 2 less Line 3)......................... 4.

– Include with Form 500 or 500X, if this schedule is applicable. – RESET INDCR03 PREVIOUS PAGE

YOUR SOCIAL SECURITY NUMBER Form IND-CR 204 State of Georgia Individual Credit Form Georgia Department of Revenue 2022

1 Page (Rev. 06/22/22) (Approved web version) 10% 150 Qualified Caregiving Expense Credit - Tax Credit 204

O.C.G.A. § 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. Additional Qualifying Family Member Name, if applicable: Qualifying Family Member Name: Age, if 62 or over If disabled, date of disability Name: SS# Relationship Age, if 62 or over If disabled, date of disability Name: SS# Relationship 3. 1. Qualified caregiving expenses........................................................................... 2. Percentage limitation....................................................................................... 3. Line 1 multiplied by Line 2................................................................................ 4. Maximum credit............................................................................................... 5. Enter the lesser of Line 3 or Line 4 ...................................................................... 2. 1. 4. 5. 6. Credit used this tax year (enter here and include on IND-CR Summary Worksheet Line 4)....................................................................................................................

6. – Include with Form 500 or 500X, if this schedule is applicable. – RESET INDCR04 PREVIOUS PAGE

YOUR SOCIAL SECURITY NUMBER Form IND-CR 206 State of Georgia Individual Credit Form Georgia Department of Revenue 2022 1 Page (Rev. 06/22/22) (Approved web version) 500 3. Amount of the disaster assistance received................................................. 4. Maximum credit........................................................................................ 5. Enter the lesser of Line 3 or Line 4................................................................. Disaster Assistance Credit - Tax Credit 206 O.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: Grants from the Department of Human Services’ Individual and Family Grant Program. 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 2. Date assistance was received.................................................................... 2. 3. 4. 5. 6. Credit used this tax year (enter here and include in IND-CR Summary Worksheet Line 6).......................................................................................... 6. 7. Carryover to next tax year (Line 1 plus Line 5 less Line 6) ............................ 7. 1. Credit remaining from previous years............................................................ 1. , , , – Include with Form 500 or 500X, if this schedule is applicable. – RESET INDCR06 PREVIOUS PAGE

YOUR SOCIAL SECURITY NUMBER Form IND-CR 207 State of Georgia Individual Credit Form Georgia Department of Revenue 2022

1 Page (Rev. 06/22/22) (Approved web version) Rural Physicians Credit - Tax Credit 207

2. 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. For taxable years beginning on or after January 1, 2022, the United States Decennial Census of 2020 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

3. 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.

1. County of residence 2. County of practice 3. Type of practice 4. Date started working as a rural physician 5. Number of hospital beds in the rural hospital 1. County of residence 2. County of practice 3. Type of practice 4. Date started working as a rural physician 5. Number of hospital beds in the rural hospital O.C.G.A. § 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: Taxpayer Spouse Only enter the information for the taxpayer and/or the spouse if they are a rural physician.

6. Rural physicians credit, enter $5,000 per rural physician......... 6. 7. 7. Credit used this tax year (enter here and include on IND-CR Summary Worksheet Line 7)..................................................... – Include with Form 500 or 500X, if this schedule is applicable.

– 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. RESET INDCR07 PREVIOUS PAGE

YOUR SOCIAL SECURITY NUMBER Form IND-CR 208 State of Georgia Individual Credit Form Georgia Department of Revenue 2022

1 Page (Rev. 06/22/22) (Approved web version)

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. Adoption of a Foster Child Credit for Adoptions Occurring in Taxable Years Beginning on or After January 1, 2008 and before January 1, 2021

1. Credit remaining from previous years.................................................. 1. 2. Enter $2,000 per qualified foster child.................................................. 2. 3. Credit used this tax year (enter here and include on IND-CR Summary Worksheet Line 8)................................................................................. 3. 4. Carryover to next year (Line 1 plus Line 2 less Line 3)........................ 4. – Include with Form 500 or 500X, if this schedule is applicable. – RESET INDCR08 PREVIOUS PAGE

YOUR SOCIAL SECURITY NUMBER Form IND-CR 209 State of Georgia Individual Credit Form Georgia Department of Revenue 2022

1 Page (Rev. 06/22/22) (Approved web version) 33.33% 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. Eligible Single-Family Residence Tax Credit - Tax Credit 209 O.C.G.A. § 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) A residence 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. The taxpayer must have claimed the credit in 2009 in order to claim the unused credit below. 1. 1. Total credit. (Enter amount from 2009 IND-CR, Part 9, Line 5.)............................... 2. Maximum allowed per year................................................................................... 3. Maximum credit allowed, (multiply Line 1 by Line 2)................................................ 3. 2. 4. Enter unused credit (Total credit less amounts used in previous years).................. 5. Credit allowed, lesser of Line 3 or Line 4.................................................................. 4. 5. 6. Credit used this tax year (enter here and include on IND-CR Summary Worksheet Line 9)........................................................................................................................ 6. 7. Carryover to next tax year (Line 4 less Line 6)............................................................. 7. – Include with Form 500 or 500X, if this schedule is applicable. – RESET INDCR09 PREVIOUS PAGE

Form IND-CR 212 State of Georgia Individual Credit Form Georgia Department of Revenue 2022 1 Page (Rev. 06/22/22) (Approved web version) YOUR SOCIAL SECURITY NUMBER 1000

500

375

750

Community Based Faculty Preceptor Tax Credit - Tax Credit 212 O.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 nurse as defined in O.C.G.A. § 43-26-3 or a physician assistant as defined in O.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 I certify that I 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 1. Number of Rotations (enter no more than 3) X (not to exceed $1,500)................................................... Fourth through Tenth Rotation First through Third Rotation 2. Number of Rotations (enter no more than 7) X (not to exceed $7,000) ............................................................ 3. Add Line 1 and Line 2, Current Year Credit Amount (cannot exceed $8,500)............. 1. 2. 3. B. Community Based Faculty Preceptor Tax Credit for an advanced practice registered nurse or physician assistant. 1. Number of Rotations (enter no more than 3) X (not to exceed $1,125)................................................... First through Third Rotation 1. Fourth through Tenth Rotation 2. Number of Rotations (enter no more than 7) X (not to exceed $5,250)................................................... 2. 3. Add Line 1 and Line 2, Current Year Credit Amount (cannot exceed $6,375)............. 3. 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)................................................ 1. – Include with Form 500 or 500X, if this schedule is applicable. – RESET INDCR12 PREVIOUS PAGE

YOUR SOCIAL SECURITY NUMBER Form IND-CR 213 State of Georgia Individual Credit Form Georgia Department of Revenue 2022

1 Page (Rev. 06/22/22) (Approved web version)

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

Adoption of a Foster Child Credit for Adoptions Occurring in Taxable Years Beginning on or After January 1, 2021- Tax Credit 213

1. Enter $6,000 per qualified foster child (if in first five taxable years of the adoption)...................................................................................... 1. 2. Enter $2,000 per qualified foster child (for years after first five taxable years of adoption)....................................................................... 2. 3. Add Line 1 and Line 2, Current Year Credit Amount ............................. 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. RESET INDCR13 PREVIOUS PAGE

YOUR SOCIAL SECURITY NUMBER Form IND-CR 214 State of Georgia Individual Credit Form Georgia Department of Revenue 2022

1 Page (Rev. 06/22/22) (Approved web version) Teacher Recruitment and Retention Credit – Tax Credit 214

A taxpayer who is designated by the Department of Education as a participating teacher in the teacher recruitment and retention program provided for in Code Section 20-2-251 shall be allowed a credit against the tax imposed by Code Section 48-7-20 in an amount equal to $3,000.00 per school year for up to five school years, which must be consecutive. Only teachers who have been designated as qualifying by the Department of Education should complete this form. For more information about the designation: https://www.gadoe.org Please note:

Each designated teacher may claim a credit amount of $3,000.00 per qualifying school year for no more than five school years, which must be consecutive, subject to conditions set forth in Code Section 20-2-251.

The credit taken on any year tax return cannot exceed your tax liability for the year. Any unused amounts of the credit can be carried forward for three years.

For more information, see Georgia Code Sections 20-2-251 and 48-7-29.23. 1. Credit remaining from previous year ................................................................................

1. – Include with Form 500 or 500X, if this schedule is applicable.– 2. 4. Credit used this tax year (enter here and include on IND-CR Summary Worksheet Line 12) .............................................................................................................................. 2. 4. 5. Potential carryover to next tax year (Line 3 less Line 4)......................................................

5.

Credit generated this tax year .......................................................................................... .

3. 3.

Total credit available (Line 1 + Line 2).............................................................................. . RESET INDCR14 PREVIOUS PAGE

Georgia FormIND-CR Summary Worksheet (Rev. 06/22/22) State of Georgia Individual Credit Form Georgia Department of Revenue 2022 YOUR SOCIAL SECURITY NUMBER

1 Page (Approved web version) IND-CR SUMMARY SCHEDULE WORKSHEET All applicable IND-CR Schedules (201, etc.) must be attached to Form 500 or Form 500X. Keep IND-CR Summary Worksheet for your records.

1. Only Georgia Individual Tax Credits (series 200) are claimed on Form IND-CR supporting schedules (IND-CR 201 through 214). 2. Enter the amount of credit used for the current tax year from each applicable IND-CR schedules on Lines 1-12. 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 13 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.

7. Rural Physicians Credit (IND-CR 207, Line 7) ...................................................... 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)...............................................................................................

9. Eligible Single-Family Residence Credit (IND-CR 209, Line 6) ............................. 7. 8. 12. Teacher Recruitment and Retention Credit (IND-CR 214, Line 4)......................... 12. 9. 3. Georgia National Guard /Air National Guard Credit (IND-CR 203, Line 3) ............ 4. Qualified Caregiving Expense Credit (IND-CR 204, Line 6) .................................. 5. Reserved ............................................................................................................... 6. Disaster Assistance Credit (IND-CR 206, Line 6) .................................................. 3. 4. 6. 5. 1. Disabled Person Home Purchase or Retrofit Credit (IND-CR 201, Line 3) ............ 2. Child and Dependent Care Expense Credit (IND-CR 202, Line 4) ........................ 2. 1.

10. Community Based Faculty Preceptor Credit (IND-CR 212, Line C1) .................. 10. 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)................................

11.

13. Total of Lines 1 through 12 (Enter here and on Form 500/500X, Page 3 Line 19) 13.

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