Form Crf-005 - Responsible Party Information
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(Rev. 7/12)
CRF-005
Form
Georgia Department of Revenue
Registration & Licensing Unit
PO Box 49512
Atlanta, GA 30359-1512
Fax: 404-417-4317 or 404-417-4318
Call: 1-877-423-6711
Georgia Department of Revenue
Email:
ST-License@dor.ga.gov
Responsible Party Information
TSD-withholding-lic@dor.ga.gov
Step 1
Read this information first
Under section 48-2-52 of the Official Code of Georgia Annotated, a:
corporation officer or employee,
limited liability company member, manager or employee, or
limited liability partnership, partner or employee
may be held personally liable for unpaid sales tax, withholding tax, and 911 charges on prepaid wireless services assessed against such
corporation, limited liability company, or limited liability partnership.
Form CRF-005 should be completed for each of the persons described above who is under a duty to collect, account for and pay any of
the above-described taxes or amounts to the Department of Revenue.
Form CRF-005 should also be used to notify the Department of Revenue when there is a change in responsible persons. Attach
additional pages if needed.
Step
2
Identify the business registered or to be registered for any of the tax types or charges listed in Step 1
Business Name
Business Address
Federal Employer Identification Number
Daytime Telephone Number
Date
Name of person completing this form
Title
Step 3
Identify the person(s) responsible for filing your business' returns and/or paying all tax or charges due
First Name
Middle Initial Last Name
Job Title
Social Security Number
Mailing Address (
number, street, and room or suite no.)
City
State
ZIP code
Phone Number
Enter dates when responsibility begins and ends (if applicable):
Email Address
From:
To:
Check all for which person is responsible:
S
l a
s e
a
n
d
U
s
e
T
x a
W
i
h t
h
o
d l
n i
g Tax
911 Charges on Prepaid Wireless Services
Complete the following if you need to identify
another person
First Name
Middle Initial Last Name
Job Title
Social Security Number
Mailing Address (
number, street, and room or suite no.)
City
State
ZIP code
Phone Number
Enter dates when responsibility begins and ends (if applicable):
Email Address
From:
To:
Check all for which person is responsible:
S
l a
s e
a
n
d
U
s
e
T
x a
911 Charges on Prepaid Wireless Services
W
i
h t
h
o
d l
n i
g Tax
Complete the following if you need to identify another person
First Name
Middle Initial Last Name
Job Title
Social Security Number
Mailing Address (
number, street, and room or suite no.)
City
State
ZIP code
Phone Number
Enter dates when responsibility begins and ends (if applicable):
Email Address
From:
To:
Check all for which person is responsible:
S
l a
s e
a
n
d
U
s
e
T
x a
W
i
h t
h
o
d l
n i
g Tax
911 Charges on Prepaid Wireless Services
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Parent category: Financial