1 2 9 0 1 3 4 3 5 3 6 3 7 3 8 3 9 3 0 4 1 4 2 4 3 4 5 4 6 ... 3 3 4 3 5 3 6 3 7 3 8 3 9 4 0 4 1 4 2 4 3 4 4 4 5 4 6 4 7 4 8 4 9 5 0 5 1 5 2 5 3 5 4 5 5 5 6 5 7 5 8 5 9 6 0 6 1 6 2 6 3 6 4 6 5 6 6 6 7 6 8 6 9 7 0 7 1 7 2 7 3 7 ...

Download 1 2 9 0 1 3 4 3 5 3 6 3 7 3 8 3 9 3 0 4 1 4 2 4 3 4 5 4 6 ...  3 3 4 3 5 3 6 3 7 3 8 3 9 4 0 4 1 4 2 4 3 4 4 4 5 4 6 4 7 4 8 4 9 5 0 5 1 5 2 5 3 5 4 5 5 5 6 5 7 5 8 5 9 6 0 6 1 6 2 6 3 6 4 6 5 6 6 6 7 6 8 6 9 7 0 7 1 7 2 7 3 7 ...

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    G-1003 (Rev. 11/11)Income Statement Return

    DO NOT SUBMIT PAYMENT WITH THIS FORMGA Withholding ID FEI Number Tax Year Number of Forms Vendor Code

    EMPLOYER NAME AND ADDRESS

    Check here if correction to Social Security Numbers only.

    Form Type

    W-2 G-2-A 1099 W2-C

    TerutangiS itle

    etaDenohpeleT

    dlehhtiWxaTaigroeGsegaWelbaxaTaigroeG

    I declare under the penalty of perjury that this return has been examined by me and to the best of my knowledge is a true and completereturn.

    Cut on dotted line

    Instructions for Preparing the G-1003If you file and pay electronically, you must file the G-1003 and related income statements electronically. Also,employers who are federally required to file income statements electronically must file them electronically for Georgia purposes. Reg. 560-7-8-.33. Even if the employer is not required to file electronically, they may choose to do so. To obtain a copy of our specifications, visit our website, www.gataxinfo.org, or call 1-877-GADOR11 (1-877-423-6711).

    Income statements are due on or before February 28th of the following calendar year. If this date is a

    Submit non-wage statements (1099s) only if Georgia tax is withheld. Statements that do not indicateGeorgia tax withheld may be filed under the Combined Federal/State Filing Program.

    The Number of Forms, Form Type, Georgia Taxable Wages and Georgia Tax Withheld blocks must

    Submit Form G-1003 and paper copies of income statements to:

    Georgia Department of RevenueProcessing CenterP.O. Box 105685Atlanta, GA 30348-5685

    PLEASE DO NOT mail this entire page. Please cut along dotted line and mail coupon only.PLEASE DO NOT STAPLE OR PAPER CLIP.

    Amended ReturnDomestic employerwith no GA Tax Withheld

    GEORGIA DEPARTMENT OF REVENUEPROCESSING CENTERP O BOX 105685ATLANTA, GA 30348-5685

    be completed.

    Date Received

    Copies of the corrected W2s/1099/G2As must accompany all amended returns.

    2012

    2012

    weekend or holiday, the due date is the next business day. If a business closes during the taxable year,income statements are due within 30 days after payment of final wages. Please not for a flow-throughentity, the G-1003 and the related G-2-As for distributions to nonresident members are due by the earlierof the date such entitys income tax return is filed or the due date for filing such entitys income tax return(without extension).

    Text2: 0: NNNNNNN-AA1: 0: NN-NNNNNNN1: NNN

    Text3: 0: x1: 0: 0: x1: x

    1: 0: x1: x

    2: 0: x1: x

    Text4: 10300000000000000000000000000000000000000000000000Text6: 1: 1: 1: 1: NNN-NNN-NNNN

    Text1: AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AA NNNNN-NNNNText10: 0: NNNNNNNN.NN1: NNNNNNNN.NN

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