Form Crf-002 - State Tax Registration Application Page 2
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CRF-002
(Rev. 2/13)
Form
S ection 5
Business Ownership/Relationship (continued)
1.
Name
Social Security Number / Taxpayer Identification Number
Mailing Address
City
County
State
Zip Code + 4
Check one:
Owner
Other
Effective Date: _______________
LLC Member
Partner
Officer
Check any/all if applicable:
Alcohol Licensee
Effective Date:
Tobacco Licensee
Effective Date :
S ection 6
Business Activity Information
1.
Check business activity type. If you check two or more boxes, list approximate percentages of receipts.
2.
Will you be selling motor
%
%
%
%
%
Retail
Manufacturing
Wholesale
Construction
Service
fuel or gasoline?
Yes
No
3.
Are you a common carrier?
Yes
No
4.
Please describe products to be sold and/or taxable services to be provided:
5.
Enter business' NAICS code number
if known:
Section 7
Employer Withholding Information
1
. Will your business have employees?
Yes
No If you answered Yes, please complete lines 2 through 5.
2.
Who will be responsible for filing and remitting payroll taxes for your employees?
Your Business
Payroll Service
Other:
3.
If you checked payroll service or other in question 2 above, enter the name and withholding tax number of the entity reporting and paying these taxes:
Name:
Withholding Tax Account Number:
4
. Do you expect to withhold more than $200 per month?
Yes
No
5.
What is the first date on which wages will be paid to employees?
Section 8
Authorized Signature/Contact Information
Under penalties of perjury, I declare that I have examined this State Tax Registration Application and to the best of my
knowledge and belief, it is true, correct and complete. I understand that to willfully prepare or present a document that is
fraudulent or false is a criminal misdemeanor under O.C.G.A. § 48 -1- 6.
Authorized Signature
Title
Date (mm/dd/yyyy)
Print Name
Daytime Telephone Number
Title
Print Third Party Preparer's Name (if any)
Daytime Telephone Number
Title
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