Form Crf-004 - Additional Ownership / Relationship Form
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1CRF-004 (Rev. 5/05)
GEORGIA DEPARTMENT OF REVENUE
REGISTRATION UNIT
P. O. BOX 49512
ATLANTA, GA 30334-8428
404-417-4490
TSD-sales-tax-lic@dor.ga.gov
ADDITIONAL OWNERSHIP / RELATIONSHIP FORM
(Complete Only If Necessary)
(PLEASE PRINT OR TYPE)
FOR OFFICE
LEGAL BUSINESS NAME:
USE ONLY
CHECK ALL THAT APPLY
EFFECTIVE DATE ___
/___________
/ _____
Owner
Officer
Alcohol Licensee
Related Business
Partner
Managing Member
Tobacco Licensee
Parent Company
A
BUSINESS NAME
STI or LICENSE NO.
B
GA. SALES TAX NO.
GA. WITHHOLDING TAX NO.
C
LAST NAME
FIRST NAME
M.I.
TITLE
SOCIAL SECURITY NO.
D
ADDRESS
E
CITY
STATE
ZIP
COUNTY
COUNTRY
PHONE
(
)
CHECK ALL THAT APPLY
EFFECTIVE DATE
____/
/___________
_____
Owner
Officer
Alcohol Licensee
Related Business
Partner
Managing Member
Tobacco Licensee
Parent Company
A
BUSINESS NAME
STI or LICENSE NO.
B
GA. SALES TAX NO.
GA. WITHHOLDING TAX NO.
C
LAST NAME
FIRST NAME
M.I.
TITLE
SOCIAL SECURITY NO.
D
ADDRESS
E
CITY
STATE
ZIP
COUNTY
COUNTRY
PHONE
(
)
CHECK ALL THAT APPLY
EFFECTIVE DATE
/
/
Owner
Officer
Alcohol Licensee
Related Business
Partner
Shareholder
Tobacco Licensee
Parent Company
A
BUSINESS NAME
STI or LICENSE NO.
GA. SALES TAX NO.
GA. WITHHOLDING TAX NO.
B
C
LAST NAME
FIRST NAME
M.I.
TITLE
SOCIAL SECURITY NO.
D
ADDRESS
E
CITY
STATE
ZIP
COUNTY
COUNTRY
PHONE
(
)
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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