Fillable 500 2017 Individual Income Tax-Return GA500

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500 2017 Individual Income Tax-Return GA500

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Georgia Form 500 (Rev. 06/22/17)
Individual Income Tax Return
Georgia Department of Revenue
2017
(Approved web version)
Fiscal Year
Beginning
Page
1
Fiscal Year
ver
Ending
YOUR DRIVER’S LICENSE/STATE ID STATE ISSUED
YOUR FIRST NAME MI YOUR SOCIAL SECURITY NUMBER
1.
LAST NAME 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)
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.................................................................................................................
4.
1. FULL- YEAR RESIDENT 2. PART- YEAR RESIDENT TO 3. NONRESIDENT
Part-Year Residents and Nonresidents must omit Lines 9 thru 14 and use Form 500 Schedule 3.
Filing Status
5. Enter Filing Status with appropriate letter (See IT - 5 1 1 Tax Booklet) ... .......................................................................... .............. 5.
A. Single B.Married filing joint
C. Married filing separate(Spouse’s social security number must be entered above)
D. Head of Household or Qualifying Widow(er)
6. Number of exemptions (Check appropriate box(es) and enter total in 6c.)
6a. Yourself 6b. Spouse 6c.
GGNNIISSSSEECCOORRPP RROOFF DDEERRIIUUQQEERR EERRAA ))55--11(( SSEEGGAAPP LLLLAA
DUALTT-IVTW-CBEX-WVRB-GSCU
HELP
PRINT
RESET
PLEASE, USE THE BLUE PRINT BUTTON TO PRINT THIS FORM. THANK YOU.
G A
Georgia Form 500
Individual Income Tax Return
Georgia Department of Revenue
2017
7a.
7b. Enter the total number of exemptions and dependents (Add Lines 6c and 7a)........................................................................
7a. Number of Dependents (Enter details on Line 7c., and DO NOT include yourself or your spouse).....................................
YOUR SOCIAL SECURITY NUMBER
2
Page
7b.
7c. Dependents (If you have more than 5 dependents, attach a list of additional dependents)
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
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 1040,1040A or 1040 EZ).
If amount on line 8, 9, 10, 13 or 15 is negative, use the minus sign (-). Example -3,456.
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 and 2.
10.
9.
00
.
00
00
.
.
INCOME COMPUTATIONS
ALL PAGES (1-5) ARE REQUIRED FOR PROCESSING
SELECT
SELECT
SELECT
SELECT
SELECT
Georgia Form 500
Individual Income Tax Return
Georgia Department of Revenue
2017
Pag e
3
YOUR SOCIAL SECURITY NUMBER
11. Standard Deduction
(Do not use FEDERAL STANDARD DEDUCTION) .............
11a.
.
00
(See IT-511 Tax Booklet)
b.
Self: 65 or over? Blind?
Total x 1,300
=.........
.
0
0
11b.
Spouse: 65 or over? Blind?
.
00
c. Total Standard Deduction (Line 11a + Line 11b)........................................
11c.
Use EITHER Line 11c OR Line 12c (Do not write on both lines)
12. Total Itemized Deductions used in computing Federal Taxable Income. If you use itemized deductions, you must include Federal Schedule A
.
00
a. Federal Itemized Deductions (Schedule A-Form 1040) .....................
12a.
b. Less adjustments: (See IT-511 Tax Booklet) ...................................
00
12b.
00
c. Georgia Total Itemized Deductions
......................................................
12c.
.
00
13. Subtract either Line 11c or Line 12c from Line 10; enter balance.
.............
13.
.
00
14a. Enter the number from Line 6c. Multiply by $2,700 for filing status A or D
14a.
or multiply by $3,700 for filing status B or C
.
00
1
4b. Enter the number from Line 7a. Multiply by $3,000............................................. 14b.
.
00
14c. Add Lines 14a. and 14b. Enter total............................................................... 14c.
15. Georgia taxable income (Line 13 less Line 14c or Schedule 3, Line 14).....
.
00
15.
16. Tax (Use Tax Table in the IT-511 Tax Booklet).................................................
16.
.
00
17.
Low Income Credit
17a. 17b.
..............................
17c.
.
00
18.
Other State(s) Tax Credit (Include a copy of the other state(s) return)........
18.
.
00
19.
C
redits used from IND-CR Summary Worksheet..........................................
19.
.
00
20.
Total Credits Used from Schedule 2 Georgia Tax Credits ..........................
20.
.
00
21.
Total Credits Used (sum of Lines 17-20) cannot ex
ceed Line 16
.......................
..........
21.
.
00
22. Balance (Line 16 less Line 21) if zero or less
than zero, enter
zero ............
22.
.
00
23.
Georgia Income Tax Withheld on Wages and 1099s .............................
23.
.
00
(Enter Tax Withheld Only and include W-2s and/or 1099s)
2 4. Other Georgia Income Tax Withheld
.......................................................
24.
.
00
(Must include G2-A, G2-FL, G2-LP and/or G2-RP)
PLEASE COMPLETE INCOME STATEMENT DETAILS ON PAGE 4.
ALL PAGES (1-5) ARE REQUIRED FOR PROCESSING
.
.
Georgia Form 500
Individual Income Tax Return
Georgia Department of Revenue
2017
Page
4
YOU
R SOCIAL SECURITY NUMBER
INCOME STATEMENT DETAILS Only enter income o n which Georgia Tax was withheld. Enter 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 Form G2-FL enter zero.
(INCOME STATEMENT A)
(INCOME STATEMENT B)
(INCOME STATEMENT C)
1.
WITHHOLDING TYPE:
1.
WITHHOLDING TYPE:
1.
WITHHOLDING TYPE:
W
-2s
G2-A G2-LP
W
-2s
G2-A G2-LP
W
-2s
G2-A G2-LP
1099s
G2-FL
G2-RP
1099s
G2-FL
G2-RP
1099s
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
.
00
.
00
.
00
5.
GA TAX WITHHELD
5.
GA TAX WITHHELD
5.
GA TAX WITHHELD
.
00
.
00
.
00
( I N C O ME STATEMENT D)
(INCOME STATEMENT E)
(INCOME STATEMENT F)
1
.
WITHHOLDING TYPE:
1.
WITHHOLDING TYPE:
1.
WITHHOLDING TYPE:
W
-2s
G2-A G2-LP
W
-2s
G2-A G2-LP
W
-2s
G2-A G2-LP
1099s
G2-FL
G2-RP
1099s
G2-FL
G2-RP
1099s
G2-FL
G2-RP
2.
EMPLOYER/PAYER FEDERAL
ID NUMBER (FEINID 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
.
00
.
00
.
00
5.
GA TAX WITHHELD
5.
GA TAX WITHHELD
5.
GA TAX WITHHELD
.
00
.
00
.
00
Please complete the Supplemental W-2 Income Statement if additional space is needed.
2
5.
Estimated T
ax
paid for 2017 and Form IT-560 ...........................................
25.
00
26. Total prepayment credits (Add Lines 23, 24 and 25).................................
26.
27.
28.
00
27. If Line 22 exceeds Line 26, subtract Line 26 from Line 22 and enter
balance due..............................................................................................
.
00
28.
If Line 26 exceeds Line 22, subtract Line 22 from Line 26 and enter
.
00
overpayment............................................................................................
29. Amount to be credited to 2018 ESTIMATED TAX .................................
29.
.
00
Pages (1-5) are Required for Processing
.
.
Georgia Form 500
Individual Income Tax Retu rn
Georgia Department of Revenue
2017
Page
5
YOU
R SOCIAL SECURITY NUMBER
.
00
30. Georgia Wildlife Conservation Fund (No gift of less than $1.00).............
30.
00
31. Georgia Fund for Children and Elderly (No gift of less than $1.00)........
31.
00
32. Georgia Cancer Research Fund (No gift of less than $1.00) .................
32.
33. Georgia Land Conservation Program (No gift of less than $1.00)...........
33.
.
00
.
00
34. Georgia National Guard Foundation (No gift of less than $1.00) .............
34.
.
00
35. Dog & Cat Sterilization Fund (No gift of less than $1.00).......................
35.
.
00
36.
Saving the Cure Fund (No gift of less than $1.00).................................
36.
.
00
37.
Realizing Educational Achievement Can Happen (REACH) Program .............
37.
(No gift of less than $1.00)
.
00
38. Public Safety Memorial Grant (No gift of less than $1.00).......................
Form 500 UET (Estimated tax penalty) 500 UET exception attached..
38.
39.
39.
00
40.
00
THIS IS YOUR REFUND.................................................................................
41.
.
00
Routing
41a.
Direct Deposit
(For U.S. Accounts Only)
Type:
Checking Savings
Number
A
ccount
Number
PROCESSING CENTER
GEORGIA DEPARTMENT OF REVENUE
PO BOX 740399
ATLANTA, GA 30374-0399
If you do not enter Direct Deposit information or if
you are a first time filer a paper check will be issued.
(REFUND and NO
PROCESSING CENTER
(PAYMENT) GEORGIA DEPARTMENT OF REVENUE
PO BOX
740380
ATLANTA, GA 30374-0380
BALANCE DUE)
INCLUDE ALL ITEMS IN ENVELOPE, DO NOT STAPLE YOUR CHECK, W-2s, OTHER WITHHOLDING DOCUMENTS, OR TAX RETURN.
I/We declare under the penalties of perjury that I/we have examined this return (including accompanying schedules and statements) and to the best of my/our knowledge
and belief, it is true, correct, and complete. If prepared by a person other than the taxpa yer(s), this declaration is based on all information of which the preparer has knowledge.
Georgia 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.
Taxpayer’s Signature
Date
(Check box if deceased)
Spouse’s Signature
Date
(Check box if deceased)
Taxpayer’s Phone Number
I 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 Firm Name
Preparer’s FEIN
Preparer’s SSN/PTIN/SIDN
ALL PAGES (1-5) ARE REQUIRED FOR PROCESSING
40.
(If you owe) Add Lines 27, 30 thru 39
MAKE CHECK PAYABLE TO GEORGIA DEPARTMENT OF REVENUE..
41.
(If you are due a refund) Subtract the sum of Lines 29 thru 39 from Line 28
.
.
.
.
Page
1
Georgia Income Statement Details
Supplemental W-2 Income Statement
Georgia Department of Revenue
2017
(Approved web version)
YOUR SOCIAL SECURITY NUMBER
INCOME STATEMENT DETAILS nly enter o G Enter 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:
W-
2s
G2-A G2-LP
W-
2s G2-A
G2-LP
W-
2s G2-A
G2-LP
1099s
G2-FL
G2-RP
1099s
G2-FL
G2-RP
1099s
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
.
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)
1.
WITHHOLDING TYPE:
1.
WITHHOLDING TYPE:
1
.
WITHHOLDING TYPE:
W-
2s G2-A G2-LP
W-
2s G2-A G2-LP
W-
2s G2-A G2-LP
1099s
G2-FL
G2-RP
1099s
G2-FL
G2-RP
1099s
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
.
00
.
00
.
00
5.
GA TAX WITHHELD
5.
GA TAX WITHHELD
5.
GA TAX WITHHELD
.
00
.
00
.
00
(INCOME STATEMENT G)
(INCOME STATEMENT H)
(INCOME STATEMENT I)
1.
WITHHOLDING TYPE:
1.
WITHHOLDING TYPE:
1
.
WITHHOLDING TYPE:
W-
2s G2-A G2-LP
W-
2s G2-A G2-LP
W-
2s G2-A G2-LP
1099s
G2-FL
G2-RP
1099s
G2-FL
G2-RP
1099s
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
.
00
.
00
.
00
5.
GA TAX WITHHELD
5.
GA TAX WITHHELD
5.
GA TAX WITHHELD
.
00
.
00
.
00
Georgia Form500
(Rev. 06/22/17)
Schedule 1
Adjustments to Income
2017 (Approved web version)
ADDITIONS to INCOME
1. Interest on Non-Georgia Municipal and State Bonds......................................
2. Lump Sum Distributions.................................................................................
3. Federal deduction for income attributable to domestic production activities......
8. Social Security Benefits (Taxable portion from Federal return)....................
9. Path2College 529 Plan ...................................................................................
10. Interest on United States Obligations (See IT-511 Tax Booklet ) ................ 10.
Adjustment Amount
Adjustment Amount
Adjustment Amount
Adjustment Amount
13. Total Subtractions (Enter sum of Lines 7-12 here)........................................
6. Total Additions (Enter sum of Lines 1-5 here)..............................................
2.
00
.
00
.
00
.
00
.
00
SUBTRACTION from INCOME
Total.................................
SCHEDULE 1 ADJUSTMENTS to INCOME BASED on GEORGIA LAW (See IT-511 Booklet)
.
12. Other Adjustments (Specify)
Other (Specify)
(IRC Section 199)
3.
1.
5.
00
00
00
00
00
.
.
.
.
Type of Disability: Date of Disability:
a. Self: Date of Birth
7. Retirement Income Exclusion (See IT-511 Tax Booklet) Complete Schedule 1, page 2 if claiming Retirement Income Exclusion.
.
00
.
7a.
00
.
00
.
00
.
YOUR SOCIAL SECURITY NUMBER
4. Net operating loss carryover deducted on Federal return......................................
4.
00
.
00
.
00
.
00
.
6.
14.
Date of Disability:
Type of Disability:
b. Spouse: Date of Birth
7b.
Schedule 1
Page 1
5.
11. Georgia Net Operating loss carryover from previous years
(List only the amount used in 2017, see IT-511 Tax Booklet ).................
.11
00
.
9.
8.
12.
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 Form 500X................................
YOUR SOCIAL SECURITY NUMBER
SCHEDULE 1 RETIREMENT INCOME EXCLUSION
S
ocial 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 unearned
i
ncome 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 lott
eries, 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.
(TAXPAYER) (SPOUSE)
1. Salary and wages..................................
.
00
.
00
2. Other Earned Income (Losses)...............
3. Total Earned Income............................
4. Maximum Earned Income.....................
5. Smaller of Line 3 or 4; if zero or less, enter
zero ..................................................
6. Interest Income....................................
7. Dividend Income ..................................
8. Alimony.................................................
9. Capital Gains (Losses)...........................
10. Other Income (Losses)*...........................
11. Taxable IRA Distributions........................
12. Taxable Pensions ................................
13. Rental, Royalty, Partnership, S Corp, etc.
Income (Losses)**................................
14. Total of Lines 6 through 13; if zero or less,
enter zero ...............................................
15. Add Lines 5 and 14 ................................
16. Maximum Allowable Exclusion, if age 62-64
or less than age 62 and permanently
disabled enter $35,000, or if age 65 or
older enter $65,000. .................................
17. Smaller of Lines 15 and 16; enter here and on
Form 500, Schedule 1, Lines 7A & B........
.
00
.
00
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00
.
00
.
00
.
00
.
00
.
00
.
00
.
00
.
00
.
00
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00
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00
.
00
.
00
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00
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00
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00
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00
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00
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00
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00
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00
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00
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00
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00
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00
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00
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00
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Schedule 1
Page 2
Georgia Form500
(Rev. 06/22/17)
Schedule 1
Adjustments to Income
2017 (Approved web version)
4 0 0 0
4 0 0 0
Schedule 2
Page 1
Georgia Form500
(Rev. 06/22/17)
Schedule 2
Georgia Tax Credits
2017 (Approved web version)
YOUR SOCIAL SECURITY NUMBER
SCHEDULE 2 GEORGIA TAX CREDIT USAGE AND CARRYOVER See IT-511 Tax Booklet for Instructions
For the credit generated this year (series 100), list the Company/Individual Name, FEIN/SSN, Credit Certificate Number, if applicable, and %
of credit (purchased credits should also be included). If the credit originated with this taxpayer, enter this taxpayer’s name and FEIN/SSN
below and 100% for the percentage.
1.
First Credit Code
..............................................................................................
1.
2.
Credit remaining from previous years
(If from a business, do not include
amounts elected to be applied to withholding).....................................
2.
.
00
3. Company/Individual Name % of Credit
Credit Certificate # FEIN/SSN Credit Generated in 2017
.
00
4. Company/Individual Name % of Credit
Credit Certificate # FEIN/SSN Credit Generated in 2017
.
00
5
. Company/Individual Name % of Credit
Credit Certificate # FEIN/SSN Credit Generated in 2017
.
00
.
00
6.
Total available credit for 2017 (sum
of Lines 2 through 5)
... .........................
6.
7. Enter the amount of the credit sold (Conservation Tax Credits, Film Tax
Credits and certain Historic Rehabilitation Tax Credits) ................................
.
00
7.
.
00
8.
Credit Used in 2017
......................................................................................
8.
.
00
9.
Potential carryover to 2018 (Line 6 less Lines 7 and 8)...................................
9.
10.
Second Credit Code
........................................................................................
10.
11.
Credit remaining from previous years
(If from a business, do not include
amounts elected to be applied to withholding).....................................
11.
.
00
12. Company/Individual Name % of Credit
Credit Certificate # FEIN/SSN Credit Generated in 2017
.
00
13. Company/Individual Name % of Credit
Credit Certificate # FEIN/SSN Credit Generated in 2017
.
00
SELECT
SELECT
Schedule 2
Page 2
Georgia Form 500
(Rev. 06/22/17)
Schedule 2
Georgia Tax Credits
2017 (Approved web version)
YOUR SOCIAL SECURITY NUMBER
SCHEDULE 2 GEORGIA TAX CREDIT USAGE AND CARRYOVER (continued)
14. Company/Individual Name % of Credit
Credit Certificate # FEIN/SSN
Credit Generated in 2017
.
00
.
00
1
5
.
Total available credit for 2017 (sum
of Lines 11 through 14
)
........................
15.
16. Enter the amount of the credit sold (Conservation Tax Credits, Film Tax
.
00
Credits and certain Historic Rehabilitation Tax Credits) ................................
16.
.
00
17.
Credit Used in 2017
......................................................................................
17.
.
00
18.
Potential carryover to 2018 (Line 15 less Lines 16 and 17)............................
18.
19.
Third Credit Code
....................................................................................
20.
Credit remaining from previous years
(If from a business, do not include
19.
amounts elected to be applied to withholding).....................................
20.
.
00
21 . Company/Individual Name % of Credit
Credit Certificate # FEIN/SSN Credit Generated in 2017
.
00
22. Company/Individual Name % of Credit
Credit Certificate # FEIN/SSN Credit Generated in 2017
.
00
2
3. Company/Individual Name % of Credit
Credit Certificate # FEIN/SSN Credit Generated in 2017
.
00
.
00
24.
Total available credit for 2017 (sum of Lines 20 through 23).........................
24.
25. Enter the amount of the credit sold (Conservation Tax Credits, Film Tax
.
00
Credits and certain Historic Rehabilitation Tax Credits) ..............................
25.
.
00
26.
Credit Used in 2017
......................................................................................
26.
.
00
27.
Potential carryover to 2018 (Line less Lines and ).........................
27.
2
8.
Total Credit Used in 2017
(sum of Line 8, Line 17 and 2 6) enter here and
.
00
include on Form 500 or Form 500X, page 3 Line 20 ...............................
28.
SELECT
Schedule 3
Page 1
Georgia Form500
(Rev. 06/22/17)
Schedule 3
Part-Year Nonresident
2017 (Approved web version)
YOUR SOCIAL SECURITY NUMBER
DO NOT USE LINES 9 THRU 14 OF PAGES 2 and 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
INCOME NOT TAXABLE TO GEORGIA
(COLUMN
B)
GEORGIA INCOME
(COLUMN C) (COLUMN A)
1. WAGES, SALARIES, TIPS, etc 1. WAGES, SALARIES, TIPS, etc
1. WAGES, SALARIES, TIPS, etc
.
00
.
00
.
00
2. INTERESTS AND DIVIDENDS 2. INTERESTS AND DIVIDENDS
2. INTERESTS AND DIVIDENDS
.
00
.
00
.
00
3. BUSINESS INCOME OR (LOSS) 3. BUSINESS INCOME OR (LOSS)
3. BUSINESS INCOME OR (LOSS)
.
00
.
00
.
00
4. OTHER INCOME OR (LOSS) 4. OTHER INCOME OR (LOSS)
4. OTHER INCOME OR (LOSS)
.
00
.
00
.
00
5. TOTAL INCOME: TOTAL LINES 1 THRU 4 5. TOTAL INCOME: TOTAL LINES 1 THRU 4
5. TOTAL INCOME: TOTAL LINES 1 THRU 4
.
00
.
00
.
00
6. TOTAL ADJUSTMENTS FROM FORM 1040 6. TOTAL ADJUSTMENTS FROM FORM 1040
6. TOTAL ADJUSTMENTS FROM FORM 1040
.
00
.
00
.
00
7. TOTAL ADJUSTMENTS FROM FORM 500, 7. TOTAL ADJUSTMENTS FROM FORM 500,
7. TOTA
L ADJUSTMENTS FROM FORM 500,
SCHEDULE 1 SCHEDULE 1
SCHEDUL
E 1
.
00
.
00
.
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 6 AND 7
LINE 5 PLUS OR MINUS LINES 6 AND 7
.
00
.
00
.
00
9. RATIO: Divide Line 8, Column C by Line 8, Column A. Enter percentage..........
9.
% Not to exceed 100%
10a. Itemized or Standard Deduction (See IT-511 Tax Booklet).................. 10a.
.
00
10b. Additional Standard Deduction
00
Self: 65 or over? Blind?
Tota l
.
Spouse: 65 or over? Blind?
x 1,300
=
10b.
11. Personal Exemption from Form 500 (See IT-511 Tax Booklet)
11a. Enter the number on Line 6c.
from Form 500 or 500X multiply by $2,700 for
11a.
.
00
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 multiply by $3,000. 11b.
.
00
11c. Add Lines 11a. and 11b. Enter total..............................................................
.
..
.
..
.
11c.
.
00
12. Total Deductions and Exemptions:
Add Lines 10a, 10b, and 11c................
12.
.
00
13. Multiply Line 12 by Ratio on Line 9 and enter result .......................................... 13.
.
00
14. Georgia Taxable Income: Subtract Line 13 from Line 8, Column C
Enter here and on Line 15, Page 3 of
Form 500 or Form 500X................. .......
14.
List the state(
s)
in which th
e income in Column B was
earned
and/or to which it was reported.
.
00
1. 2. 3.
4.
SELECT
SELECT
SELECT
SELECT
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.
– Enclose with Form 500 or 500X, if this schedule is applicable. –
2.
3. Enter credit used in 2017 (enter here and include on IND-CR Summary Worksheet
Line 1)..............................................................................................................................
2.
3.
4. Potential carryover to 2018 (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...................................................................................................................
.
00
.
00
.
00
.
00
YOUR SOCIAL SECURITY NUMBER
SCHEDULE 201 Disabled Person Home Purchase or Retrofit Credit - Tax Credit 201
Form IND-CR 201
State of Georgia Individual Credit Form
Georgia Department of Revenue
2017(Rev. 06/22/17)
(Approved web version)
1
Page
– Enclose with Form 500 or 500X, if this schedule is applicable. –
YOUR SOCIAL SECURITY NUMBER
SCHEDULE 202 Child and Dependent Care Expense Credit - Tax Credit 202
1
Page
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 . Enter credit used in 2017 (enter here and include on IND-CR Summary Worksheet
Line 2).....................................................................................................................
.
0
.
3
00
.
%
1.
2.
4.
3.
00
.
00
Form IND-CR 202
State of Georgia Individual Credit Form
Georgia Department of Revenue
2017(Rev. 06/22/17)
(Approved web version)
– Enclose with Form 500 or 500X, if this schedule is applicable. –
YOUR SOCIAL SECURITY NUMBER
SCHEDULE 203 Georgia National Guard/Air National Guard Credit - Tax Credit 203
1
Page
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.
00
.
00
.
00
.
00
.
2. Enter amount of qualified life insurance premiums ............................................ 2.
3.
4.
Form IND-CR 203
State of Georgia Individual Credit Form
Georgia Department of Revenue
2017(Rev. 06/22/17)
(Approved web version)
3 . Enter credit used in 2017 (enter here and include on IND-CR
Summary Worksheet Line 3).....................................................................
4. Carryover to 2018 (Line 1 plus Line 2 less Line 3)................................ ... ..
– Enclose with Form 500 or 500X, if this schedule is applicable. –
YOUR SOCIAL SECURITY NUMBER
SCHEDULE 204 Qualified Caregiving Expense Credit - Tax Credit 204
1
Page
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 sub
tracted 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
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 ......................................................................
0
%
00
00
.
.
.
00
00
.
1 05
2.
1.
4.
5.
6. Enter credit used in 2017 (enter here and include on IND-CR Summary
Worksheet Line 4)...................................................................................................
6.
.
00
Form IND-CR 204
State of Georgia Individual Credit Form
Georgia Department of Revenue
2017(Rev. 06/22/17)
(Approved web version)
– Enclose with Form 500 or 500X, if this schedule is applicable. –
YOUR SOCIAL SECURITY NUMBER
SCHEDULE 205 Driver Education Credit - Tax Credit 205
1
Page
Date of Successful Completion ...............................................................
Birth Date
Second Child, if applicable
SS#
Driv er Education Credit - Tax Credit 205
O.C.G.A.§ 48-7-29.5 provides for a driver education credit. This is a credit for an amount paid for a dependent minor child
for a successfully completed course of driver education at a private driver training school licensed by the Department of
Driver Services under Chapter 13 of Title 43, “The Driver Training School and Commercial Driver Training School License
Act.” The amount of the credit is equal to $150 or the actual amount paid, whichever is less. A private driver training school
is one that primarily engages in offering driving instruction. This does not include schools owned or operated by local,
state, or federal governments. An amount paid for a completed course of driver education to a private or public high
school does not qualify for
this credit. A completed course of driver education includes additional courses offered by
private driver training schools such as defensive driver education. This tax credit is only allowed once for each dependent
minor child of a taxpayer. The amount of the tax credit cannot exceed the taxpayer’s income tax liability. The credit is not
allowed with respect to any driver education expenses either deducted or subtracted by the taxpayer to arrive at Georgia tax-
able net income or with respect to any driver education expenses for which amounts were excluded from Georgia taxable net
income. Any unused tax credit cannot be carried forward to any succeeding years’ tax liability and cannot be carried back to
any
prior years’ tax liability. Visit dds.ga.gov/Training/index.aspx.
First Child
Name of private driver training school
Name of dependent minor child
1. Amount paid for the successfully completed course(s).............................
2. Maximum credit (cannot exceed $150 per child)............................................
3. Enter the lesser of Line 1 or Line 2 ............................................................
4. Enter credit used in 2017 (enter here and include on IND-CR Summary
Worksheet Line 5)........................................................................................
00
4.
00
.
00
.
1.
2.
3.
00
.
.
Date of Successful Completion ...............................................................
Birth Date
Name of private driver training school
Name of dependent minor child
SS#
Form IND-CR 205
State of Georgia Individual Credit Form
Georgia Department of Revenue
2017(Rev. 06/22/17)
(Approved web version)
– Enclose with Form 500 or 500X, if this schedule is applicable. –
YOUR SOCIAL SECURITY NUMBER
SCHEDULE 206 Disaster Assistance Credit - Tax Credit 206
1
Page
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.
.
00
.
00
5 00
5.
.
00
6. Enter credit used in 2017 (enter here and include in IND-CR Summary
Worksheet Line 6)...........................................................................................
6.
.
00
7. Carryover to 2018 (Line 1 plus Line 5 less Line 6).........................................
7.
.
00
00
1. Credit remaining from previous years............................................................
1.
.
00
00
Form IND-CR 206
State of Georgia Individual Credit Form
Georgia Department of Revenue
2017(Rev. 06/22/17)
(Approved web version)
– Enclose with Form 500 or 500X, if this schedule is applicable. –
YOUR SOCIAL SECURITY NUMBER
SCHEDULE 207 Rural Physicians Credit - Tax Credit 207
1
Page
Rural Physicians Credit - Tax Credit 207
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
6. Rural physicians credit, enter $5,000 per rural physician.........
6.
.
00
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.
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 (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.
Only enter the information for the taxpayer and/or the spouse if they are a rural physician.
7. Enter credit used in 2017 (enter here and on IND-CR Summary
Worksheet Line 7)....................................................................
7.
.
00
Form IND-CR 207
State of Georgia Individual Credit Form
Georgia Department of Revenue
2017 (Rev. 06/22/17)
(Approved web version)
– Enclose with Form 500 or 500X, if this schedule is applicable. –
YOUR SOCIAL SECURITY NUMBER
SCHEDULE 208 Adoption of a Foster Child Credit - Tax Credit 208
1
Page
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. Any unused credit can be carried forward until used.
Adoption of a Foster Child Credit - Tax Credit 208
.
00
.
00
.
00
.
00
1. Credit remaining from previous years.................................................. 1.
2. Enter $2,000 per qualified foster child.................................................. 2.
3. Enter credit used in 2017 (enter here and include on IND-CR Summary
Worksheet Line 8).................................................................................. 3.
4. Carryover to 2018 (Line 1 plus Line 2 less Line 3)............................... 4.
Form IND-CR 208
State of Georgia Individual Credit Form
Georgia Department of Revenue
2017(Rev. 06/22/17)
(Approved web version)
– Enclose with Form 500 or 500X, if this schedule is applicable. –
YOUR SOCIAL SECURITY NUMBER
SCHEDULE 209 Eligible Single-Family Residence Tax Credit - Tax Credit 209
1
Page
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 residenc
e (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.
00
00
.
.33
%
33
4. Enter unused credit (Total credit less amounts used in previous years)..................
5. Credit allowed, lesser of Line 3 or Line 4....................................................................
4.
00
.
5.
00
.
6. Credit used in 2017 (enter here and include on IND-CR Summary Worksheet
Line 9).......................................................................................................................
6.
00
.
7. Carryover to 2018 (Line 4 less Line 6).....................................................................
7.
00
.
Form IND-CR 209
State of Georgia Individual Credit Form
Georgia Department of Revenue
2017(Rev. 06/22/17)
(Approved web version)
Please print your numbers like this in black or blue ink:
Please print your numbers like this in black or blue ink:
1
Page
.
00
.
00
.
00
.
00
.
00
.
00
.
00
.
00
.
00
.
00
Georgia Form IND-CR
Summary Worksheet (Rev. 06/22/17)
State of Georgia Individual Credit Form
Georgia Department of Revenue
2017(Approved web version)
IND-CR SUMMARY SCHEDULE WORKSHEET
YOUR SOCIAL SECURITY NUMBER
1. Only Georgia Individual Tax Credits (series 200) are claimed on Form IND-CR supporting schedules (IND-CR 201
through 209).
2. Enter the amount of credit used in 2017 from each applicable IND-CR schedule on Lines 1-9.
3. If there is a credit remaining from previous years eligible for carryover to 2017, the supporting IND-CR schedule must
be completed even if the credit is not used in 2017.
4. The total of Line 10 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 are claimed on Form 500 Schedule 2.
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 (IND-CR 208, Line 3) ......................................
9. Eligible Single-Family Residence Credit (IND-CR 209, Line 6) ............................
1 0 .
Total of Lines 1 through 9 (Enter here and on Form 500/500X, Page 3 Line 19)...
7.
8.
10.
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. Driver Education Credit (IND-CR 205, Line 4) ......................................................
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.
All applicable IND-CR (201-209) Schedules must be attached to Form 500 or Form 500X
Keep IND-CR Summary Worksheet for your records.
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500 2017 Individual Income Tax-Return GA500

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