Protest of Proposed Assessment or Refund Denial 
                                                              
 GENERAL INSTRUCTIONS: 
 
 PLEASE READ:   
  
 • DO use this form if you disagree with either the amount due on a Notice of Proposed Assessment or the Department's 
   denial of your request for refund.  
  
 • DO attach a copy of the Proposed Assessment or Notice of Refund Denial, as well as any supporting documents. 
  
 • DO enter the Letter ID listed on the Proposed Assessment or Notice of Refund Denial in Section 2 of this form.  This 
   information will assist the Department in timely resolving your protest. 
  
 • DO try to submit this form electronically by visiting the Department’s Georgia Tax Center at https://gtc.dor.ga.gov.  
  
 • DO NOT  submit this form if you want to request an installment payment agreement, seek a penalty waiver, or submit an 
   offer in compromise.  Go online to the Georgia Tax Center (https://gtc.dor.ga.gov) for these options. 
  
 LINE BY LINE INSTRUCTIONS: 
  
 Section 1 Select Protest Type 
 Check the appropriate box for the type of protest.  
  
 Section 2 Letter ID 
 If you received a notice from the Department showing an amount due, enter the Letter ID listed on the notice.   
  
 Check the appropriate tax type and enter the related tax identification number. 
  
 Check the appropriate box if you are being assessed as either (i) a responsible person for a sales or income tax withholding 
 liability or (ii) as a successor to a prior business. 
  
 Enter the tax periods from the Notice of Proposed Assessment or Refund Denial. 
  
 Section 3 Taxpayer Contact Information  
 Enter your Name (First, Middle Initial, and Last Name). 
  
 Enter your Social Security Number. 
  
 Enter your Spouse’s Name (First, Middle Initial, and Last Name), if a joint liability exists. 
  
 Enter your Spouse’s Social Security Number, if a joint liability exists. 
  
 Enter your Business Name, if business is being assessed. 
  
 Enter Employer Identification Number. 
  
 Enter Taxpayer’s Address (number, street, and room or suite no., city, state, ZIP code). 
  
 Enter Daytime Telephone Number. 
  
 Enter Mailing Address (if different from above) (number, street, and room or suite no., city, state, ZIP code). 
  
 Section 4 Representative Information 
  If you are being represented by an attorney, accountant or other third party complete this section. 
   
 Section 5 Conference Request 
 Check the appropriate box if you would like to request a conference with the Department. 
  
 Section 6 Reason for Protesting Proposed Assessment 
 Provide a detailed explanation of why the Department should grant your protest. 
  
 Section 7 Signatures 
 Taxpayer or Representative must sign form. 

                                                                               Print                                       Clear

          Form                   TSD-1(Rev. 12/11)                                                                                                                 Page 1

                                                                               Georgia Department of Revenue
                                                                                                                                                                                                         
                                              Protest of Proposed Assessment or Refund Denial
    ECTION        SECTION2         1    ChooseChooseProtestprotestTypet pe 
                         Protest of Proposed Assessment                     Protest of Refund Denial 
    ECTION        SECTION3        2    TaxTInformation

      Enter Letter ID number listed on the Notice of Proposed Assessment or Refund Denial                                                        (if available):   L                                    
      Check tax type and enter the related tax identification number and tax periods at issue: 
                                             SSN:                                                                                           FEIN: 
        Individual Income Tax                                                                                                                     
                                                                                                      Corporate Income Tax                                                                
                                                              -              -                                                                        - 
                                              STN:                                                                                          IFTA: GA 
        Sales and Use Tax 
                                                                                                      IFTA Fuel Tax 
                                               
                                              WTN:                                                                                          TAX ID:
        Withholding Tax                                                                               Other                                                                
                                                                                                                                                   
                                                                                        - 
                                              _ _ _ _ _ _ _ _ _ _                                                                           _ _ _     _        _ _ _              _              _ _   

        Check if you are being assessed as a       responsible person for sales or withholding                                                taxes or as a       successor to a business.

          Tax periods listed on Notice of Proposed Assessment or Refund Denial:
                                                                                                                                                                                                              
    ECTION        SECTION1          3    TaxpayeraxpayerContactntactInformation Information 
  Taxpayer’s First             Name                                 Middle Initial          Last Name                                                    Social Security Number 
                                                                                                                                                               
  Spouse’s First Name (if joint liability)                          Middle Initial          Last Name                                                    Social Security Number 
                                                                                                                                                               
    Business Name (use if business is being assessed)                                                                                                    Employer Identification Number  
     
    Taxpayer’s Address                                                         City                         State                    ZIP                 Daytime Telephone Number 

    Mailing Address                                                                                    City                                       State         ZIP
 
ECTION        SECTION4         4    RepresentativeRepresentativeInformationInformation 
Complete this section only if you are being represented by an attorney, accountant, or other third party.  A Power of Attorney (Form RD-
1061) authorizing the representative to act for the taxpayer must be included with the protest form. 
    Name                                                                                          Telephone Number                                   Fax Number 

    Mailing Address                                                                               City                                      State    ZIP 
    
ECTION        SECTION4         5    ConferenceRepresentativeRequestInformation         
Check either box: 
       Taxpayer requests a conference with a Department representative regarding the Notice of Proposed Assessment or Refund Denial. 
    
         Taxpayer does not request a conference.  The protest will be determined based upon the contents of this form, any attached
        document’s and the Department’s records.

                                                 Print                            Clear

        Form                   TSD-1(Rev. 12/11)                                                                             Page 2

  SECTION          6    Reason for Protesting Proposed Assessment
 Provide a detailed explanation concerning why the Department should grant your protest to either (i) withdraw or revise the proposed 
 assessment or (ii) grant your request for refund.  Attach additional pages, if needed, and enclose copies of any supporting documents.  
 Copies of canceled checks must include the front and back of the check. 
  
  SECTION         7     Signatures
  All protests must be signed by the taxpayer or authorized representative.  A Power of Attorney must accompany this form if 
  the form is signed by an authorized representative only.  For those taxpayers that are corporations, limited liability 
  companies, or any other legal business entity, this form must be signed by the person authorized to act in the name of the 
  business (e.g., corporate officer,      managing member, general partner, etc…).   
         
  Taxpayer’s Name                                      Taxpayer’s Signature                                                  Title (for business entity)  Date 

  Representative’s Name                                Representative’s Signature                                                                         Date 
  
                        Mail this application and all attachments to the following address:                                                               
                                                 Georgia Department of Revenue  
                                                 Taxpayer Services Division  –    Protests 
                                                          P.O. Box 105596 
                                                           Atlanta, GA 30348