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STATE OF GEORGIA

DEPARTMENTOFREVENUE

INSTRUCTIONS FOR COMPLETION OFTHE COIN-OPERATED AMUSEMENT MACHINE REN EWAL APPLICATION

TYPE OR PRINT IN INK - DO NOT USE PENCIL

Use this form to apply for a renewal license, and decals for coin-operated music or amusement machines. If you do not have a Master

Account Number with the State of Georgia, you must apply for one, using the Coin-Operated Amusement Machine Application (Form CRF-

013). Afterwards, the State of Georgia will mail a Renewal Form each year that you remain in business or operate a coin-operated machine

(Form CRF-014).

Review the information on the front of this application for correctness. If any changes are necessary, draw a line through the incorrect

information and type, or print in ink, the correct information.

If your business is currently registered under one form of ownership and will be operating under a different type of ownership structure,

you must re-apply using Form CRF-002 (e.g., business changing from a proprietorship to a corporation).

DEFINITION OF COIN-OPERATEDAMUSEMENTMACHINE:

Every machine, of any kind or character, used by the public t.o provide amusement or entertainment, whose operation requires

the payment of, or the insertion of, a coin,bill, other money, token, ticket, or similar object, and the result of whose operation

depends in whole, or in part, upon the skill of the player, whether or not it affords an award to a successful player, pursuant to

subsections (b) through (f) of Code Section 16-12-35 of the Official Code of Georgia Annotated, and which can be legally

shipped interstate according to federal law. Examples include: Pinball machines, console machines, video games, crane

machines, claw machines, pusher machines, bowling machines, novelty arcade games, foosball/table soccer machines,

miniature racetrack/football or golf machines, target/shooting gallery machines, basketball machines, shuffleboard games,

kiddie dde games, skeeball machines, air hockey machines, roll down machines, coin-operated pool table, and every

machine of any kind which provides music, such as jukeboxes.

For further information, refer to Georgia Code 48-17-1 through Code 48-17-14.

INSTRUCTIONS FOR PAYMENT:

If you are requesting the renewal of your Annual Master License, a check in the amount of $250.00 for (1-5 machines), $1,500.00 (for 6-

60 machines) or $2,500.00 (for 61 or more machines) must be attached. If requesting the renewal of your Six-Month Master License,

a check in the amount of $175.00 (for 1-5 machines), $1,050.00 (for 6-60 machines) or $1,750.00 (for 61 or more machines) must be

attached. Decals for each machine are $25 per machine.

Registration fee must be made payable to the GEORGIA DEPARTMENT OF REVENUE. Georgia law stipulates that taxes and fees shall

be paid in lawful money of the U.S. and be free of any expense to Georgia.

RELATIONSHIP SECTION:

Draw a line through any incorrect information and add new information. In order to accurately reflect the type

of company you have, it is necessary for us to enter the structure of your organization into our computer. We need to know if you are currently

a corporation (and who the officers are), or if you are a sole proprietorship (and who the owner is), or if the company is a partnership (and

who the partners are). Also, please indicate the effective dates of these officers; owners, or partners.

IMPORTANT NOTICE:

Your permits will not be issued if you or your organization have any outstanding liabilities.

NO REFUND of any of these fees is authorized if owner ceases operation prior to the end of the calendar year.

INSTRUCTIONS FORSIGNING:

This application must be signed by the owner, a partner, or an authorized officer of the corporation.

INSTRUCTIONS FOR MAILING:

Mail the original application to the address shown below. You should retain a copy of this application for your file.

GEORGIA DEPARTMENT OF REVENUE

CENTRALIZEDTAXPAYER REGISTRATION UNIT

P. O. BOX 38428

ATLANTA, GEORGIA 30334-8428

TO AVOID DELAY IN THE ISSUANCE OF YOUR LICENSE ANSWER ALL QUESTIONS COMPLETELY, ATTACH APPROPRIATE

FEES, FURNISH ALL INFORMATION AND DOCUMENTS REQUIRED, AND SIGN THE APPLICATION.

Please allow 4 to 6 weeks for processing. For further information call (404) 656-1793.

Instructions For Completion Ofthe Coin-Operated Amusement Machine Ren Ewal Application - Departmentofrevenue

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