Form Crf-002 - State Tax Registration Application March 2008 Page 2
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(Please Read Instructions Before Completing)
OWNERSHIP / RELATIONSHIP SECTION
(This section MUST be completed for your application to be accepted.)
CHECK ALL THAT APPLY (Indicate the percentage of
17
/
/___
__
EFFECTIVE DATE
interest the individual has in the business:
Owner
%
Officer
%
Manager
%
Partner
%
Member
%
Managing Member
%
Tobacco Licensee
%
Alcohol Licensee
%
A
BUSINESS NAME
STI or LICENSE NO. (If Applicable)
GA SALES TAX NO. (If Applicable)
GA WITHHOLDING TAX NO. (If Applicable)
B
C
LAST NAME
FIRST
M.I.
TITLE
SOCIAL SECURITY NUMBER
Application will not be processed unless the social security number of an owner,
officers, managing members or both partners is included. Reg. 560-1-1.18
D
ADDRESS
E
CITY
STATE
ZIP
COUNTY
COUNTRY
PHONE
18
CHECK ALL THAT APPLY
/
/___
__
EFFECTIVE DATE
Owner
%
Officer
%
Manager
%
Partner
%
Member
%
Managing Member
%
Tobacco Licensee
%
Alcohol Licensee
%
A
BUSINESS NAME
STI or LICENSE NO. (If Applicable)
B
GA SALES TAX NO. (If Applicable)
GA WITHHOLDING TAX NO. (If Applicable)
C
LAST NAME
FIRST
M.I.
TITLE
SOCIAL SECURITY NUMBER
Application will not be processed unless the social security number of an owner,
officers, managing members or both partners is included. Reg. 560-1-1.18
ADDRESS
D
E
CITY
STATE
ZIP
COUNTY
COUNTRY
PHONE
(TO REPORT ADDITIONAL RELATIONSHIPS, USE FORM CRF-004)
SALES AND USE TAX SECTION
19
NATURE OF BUSINESS (If your business is a combination of two or more, list approximate percentages of receipts. Must equal 100%.)
Retail
%
Manufacturing
%
Services (Specify)
%
Wholesale
%
Construction
%
Other (Specify)
%
20
WHAT PRODUCT WILL YOU SELL OR WHAT SERVICE WILL YOU PROVIDE? (Please be specific.)
21
DO YOU EXPECT TO REMIT MORE THAN $200 PER MONTH IN SALES TAX?
Yes
No
22
WILL YOU SELL ALCOHOLIC BEVERAGES?
Yes *
No
* Additional Forms Required
23
WILL YOU SELL TOBACCO PRODUCTS?
Yes *
No
* Additional Forms Required
24
WILL YOU SELL MOTOR FUEL?
Yes *
No
* Additional Forms Required
DO YOU COLLECT AND REMIT STATE AND LOCAL PREPAID TAX ON MOTOR FUEL SALES?
Yes
No
25
WHEN DID OR WILL YOU START SELLING OR PURCHASING ITEMS SUBJECT TO SALES TAX?
Date:
/
/
WILL YOU SELL LOTTERY AT THIS LOCATION?
No
Yes
If “Yes”, PLEASE PROVIDE YOUR RETAILER NUMBER
26
WILL YOU HAVE EMPLOYEES?
No
Yes
If “Yes”, complete the following WITHHOLDING TAX SECTION. If “No”, stop here and complete the SIGNATURE SECTION.
27
WITHHOLDING TAX SECTION
28
WHO WILL BE RESPONSIBLE FOR FILING AND REMITTING THE PAYROLL TAXES FOR YOUR EMPLOYEES?
Other
Applicant
Payroll Service
If “Payroll Service” or “Other”, list the name and GA. Withholding No. of the business responsible for paying these taxes.
NAME
GA. WITHHOLDING TAX NO.
29
DO YOU EXPECT TO WITHHOLD MORE THAN $200 PER MONTH?
Yes
No
30
HOW MANY EMPLOYEES DOES THIS BUSINESS HAVE OR WILL HAVE?
31
DATE ON WHICH WAGES WERE OR WILL FIRST BE PAID?
/
/
SIGNATURE SECTION
I HAVE EXAMINED THIS APPLICATION, AND TO THE BEST OF MY KNOWLEDGE IT IS TRUE AND CORRECT
Signature
Title
Date
MUST BE SIGNED BY OWNER, PARTNER, MANAGING MEMBER, OR
CORPORATE OFFICER AS LISTED IN THE RELATIONSHIP SECTION (17 OR 18) ABOVE.
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