Form IA-81 – Fill Out and Use This PDF

(Revised 5/12)

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: $_______________

TAXPAYER INFORMATION (E-mail: ____________________________________________)

Primary Taxpayer Name or Name of Business:

Spouse Name (if applicable):

SSN

SSN (spouse, if applicable)

-

-

-

-

State Tax Identification Number (STI)

Check Number (if known)

Mailing Address on Return:

City

State

Zip

Current Mailing Address: (if different from above)

City

State

Zip

Daytime Telephone Number

Fax Number

Name of Contact Person (if applicable)

Reasons for request (choose one):

Check Never Received

Direct Deposit Never Received

Lost

Stolen

Expired

Destroyed

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, DO NOT CASH THE ORIGINAL CHECK. You must return the check to the Department.

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.

HOW TO SUBMIT YOUR FORM:

You may submit your completed request to the Department as follows:

Mail to: Georgia Department of Revenue, 1800 Century Center Blvd NE, Suite 3104, Atlanta, GA 30345-3212

Fax: 404-417-4391