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Form IT-WH Rev 7/12 Print MAIL TO Clear NOTICE OF INTENTION TO CLAIM WITHHOLDING BENEFIT Georgia Department of Revenue Withholding Tax Section P. O. Box 49431 Atlanta GA 30359 Name of Company Address City State Federal Employer I.D. Georgia Withholding I.D. s Tax Year of Income Tax Return on which credit claimed ZIP Code Anticipated Date of Filing Qualifying Tax Credit Headquarters Job Tax Credit Job Tax Credit Film Tax Credit Research Tax Credit Quality Jobs Tax Credit Clean Energy Property Tax Credit For Headquarters Job Tax Credit Job Tax Credit OR Quality Jobs Tax Credit only Year Jobs Created County / Tier Jobs Created In order to receive the withholding tax benefit this form must be filed at least thirty 30 days prior to the due date of the Georgia income tax return including extensions or at least thirty 30 days prior to filing of the income tax return whichever occurs first. By filing this form we acknowledge we are making an irrevocable election to qualify for the withholding tax option for this tax year. Note For purposes of the Job Tax Credit this election is limited to the 3 500 2 500 1 250 or 750 credit amount per eligible employee which may be applied to withholding. Whereas the aforementioned company has established a qualified tax credit to be applied to its Georgia Income Tax liability and whereas the credit exceeds the income tax liability notice is hereby given of the company s intent to claim the excess of the income tax credit as an offset to its Georgia Withholding Tax payments paid under the provisions of Code Section 48-7-103. If the aforementioned company does not want to use all of the excess of the income tax credit as an offset to its Georgia excess is income tax credit carry forward. amount to be used against Georgia Withholding Tax payments. Offsets to Withholding Tax payments may begin on the date specified by the Department in the Confirmation of Intention to Claim Withholding Benefit letter which the Department will issue within 90 or 120 days depending on credit type of receiving the Qualifying Year s Georgia Income Tax Return* Date Contact Person Phone Number Title Email Address enterprise must attach certification from the Commissioner of Economic Development to this form* For the research tax credit earned in tax years beginning on or after January 1 2012 the amount that may be applied to withholding is the amount that exceeds 50 percent of the business enterprise s remaining Georgia net income tax liability after all other credits have been applied* Note for the 2011 tax year the withholding benefit is only available to a newly formed business enterprise which is in its first five years of operations in the state. For the clean energy property tax credit for taxpayers preapproved for calendar year 2012 2013 or 2014 the credit must be taken in four equal installments over four successive years.

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