Form Crf-004 - Additional Ownership/relationship Form - 2013
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CRF-004 (Rev. 3/13)
GEORGIA DEPARTMENT OF REVENUE
REGISTRATION and LICENSING UNIT
P. O. BOX 49512
ATLANTA, GA 30334-1512
Phone: 1-877-GADOR11 (1-877-423-6711)
TSD-sales-tax-lic@dor.ga.gov
TSD-withholding-lic@dor.ga.gov
ADDITIONAL OWNERSHIP / RELATIONSHIP FORM
(Complete Only If Necessary)
(PLEASE PRINT OR TYPE)
LEGAL BUSINESS NAME:
CHECK ALL THAT APPLY
Effective Date :
%
Partner
Officer
%
Owner
%
Other : _______________
Alcohol Licensee
%
%
%
Tobacco Licensee
LLC Member
BUSINESS NAME
STI or LICENSE NO.
GA. SALES TAX NO.
GA WITHHOLDING TAX NO.
LAST NAME
FIRST NAME
M.I.
TITLE
SOCIAL SECURITY NO.
ADDRESS
CITY
STATE
ZIP
COUNTY
PHONE NUMBER
CHECK ALL THAT APPLY
Effective Date :
%
Partner
Officer
%
Owner
%
Other : _______________
%
Alcohol Licensee
%
%
Tobacco Licensee
LLC Member
BUSINESS NAME
STI or LICENSE NO.
GA. SALES TAX NO.
GA WITHHOLDING TAX NO.
LAST NAME
FIRST NAME
M.I.
TITLE
SOCIAL SECURITY NO.
ADDRESS
CITY
STATE
ZIP
COUNTY
PHONE NUMBER
CHECK ALL THAT APPLY
Effective Date :
%
Partner
Officer
%
Owner
%
Other : _______________
Alcohol Licensee
%
%
%
Tobacco Licensee
LLC Member
BUSINESS NAME
STI or LICENSE NO.
GA. SALES TAX NO.
GA WITHHOLDING TAX NO.
LAST NAME
FIRST NAME
M.I.
TITLE
SOCIAL SECURITY NO.
ADDRESS
CITY
STATE
ZIP
COUNTY
PHONE NUMBER
SIGNATURE SECTION
I HAVE EXAMINED THIS FORM, AND TO THE BEST OF MY KNOWLEDGE IT IS TRUE AND CORRECT.
SIGNATURE
TITLE
DATE
(MUST BE SIGNED BY OWNER, PARTNER, OR CORPORATE OFFICER AS LISTED IN THE RELATIONSHIP SECTION ABOVE.)
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