(R evised 4/29/15)
Form IA-81
Replacement Check Request Form
GENERAL INSTRUCTIONS
•DO Use this form to replace a refund check that has been mailed but never received.
•DO Use this form to request a stop payment on a check that has been lost, stolen or destroyed.
•DO Use this form if you have a refund check that has expired and has not been cashed for more than 180 days after issuance.
•DON’T Request a replacement check if it has been less than 15 business days since the check was mailed.
•PLEASE Allow 10-15 business days processing time for your completed form.
REFUND TAX YEAR: _____________ |
REFUND AMOUNT: $_______________ |
Check Tax Type:
Individual |
Sales and use tax |
Withholding |
Motor Fuel |
TAXPAYER INFORMATION (E-mail: ____________________________________________)
Primary Taxpayer Name or Name of Business: |
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Spouse Name (if applicable): |
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SSN |
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SSN |
(spouse, if applicable) |
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State Tax Identification Number (STI) |
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Check Number (if known) |
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Mailing Address on Return: |
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State |
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Zip |
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Current Mailing Address: (if different from above) |
City |
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State |
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Zip |
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Daytime Telephone Number |
Fax Number |
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Name of Contact Person (if applicable) |
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Reasons for request (choose one): |
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Check Never Received |
Lost |
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Stolen |
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Expired |
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Destroyed |
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Other (Please Explain :__________________________________) |
Note: A “STOP PAYMENT” will be issued on the original refund check upon receipt of this form. If you receive/find your original check after submitting this form, please destroy the check.
DECLARATION:
I hereby declare, under penalties of perjury, that I have examined this request and, to the best of my knowledge and belief, it is true, correct and complete. If you are being represented by an attorney, accountant, or other third party, a properly executed Power of Attorney (Form RD-1061) authorizing the representative to act for the taxpayer must be included with this form.
Taxpayer’s Signature and Date
Spouse’s Signature and Date (if applicable)
Representative’s Signature
HOW TO SUBMIT YOUR FORM: You may submit your completed request to the Department as follows:
Mail to: Georgia Department of Revenue, PO Box 740389, Atlanta, GA 30374-0389