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STATE OF GEORGIA

DEPARTMENT OF REVENUE

I N S T R U C T I O N S FOR C O M P L E T I O N OF THE COIN O P E R A T E D

S T A T E A M U S E M E N T MACHINE A P P L I C A T I O N (FORM CRF-013)

TYPE OR PRINT IN INK - DO NOT USE PENCIL

Use this form to apply for a license and decals for coin-operated music or amusement machines (e.g.,): pinball machines, console machines,

video games, crane machines, claw machines, pusher machines, bowling machines, novelty arcade games, football/table soccer machines,

miniature racetrack/foosball or golf machines, target/shooting gallery machines, basketball machines, shuffleboard games, kiddie ride games,

skeeball machines, air hockey machines, roll down machines, coin-operated pool table, and every coin-operated 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.

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 owner proprietorship (and who the owner is)

or if the company is a partnership (and who the partners are). Also, please indicate the effective dates ofthese officers, owners, or partners.

This pertains to CRF-002.

INSTRUCTIONS FOR COMPLETING FORM CRF-0013:

IDENTIFICATION SECTION

Line I -

Enter your Georgia State Taxpayer Identifier. (Ifyou do not yet have one, leave blank.)

(la) EnteryourFederal Employerldentification Numberifapplicable.

Line 2 -

Enter your legal business name as listed on Form CRF-002. (2a). Enter your DBA name.

Line 3-

Enter the physical location address of your business. (A Post Office Box is not an acceptable location address.)

Line 4 -

Enter the city, county, state, zip code and phone number.

Line 5 -

Check type of ownership.

AMUSEMENT MACHINE INFORMATION SECTION

Line 6 -

Enter the date you plan to first operate in Georgia (6a). If you are in a business for only part of the year (i.e., six

months) do you want a renewal form sent to you for next year?.

Line 7 -

Enteryour State Liquor/Beer and Wine License Number. (If Applicable.)

Line 8 -

Enter your Sales, and Use Tax Number. If you do not have a Sales and Use Tax number and are responsible for the

collection of sales tax, complete the Sales and Use Tax Part of Form CRF-002.

Line 9 -

Enter your Georgia Withholding Tax Number. If you have employees in Georgia and do not have a Withholding

Number, complete the Withholding part of Form CRF-002.

Line 10-

List the local governments/counties in which you pay ad valorem tax. If additional space is needed, attach a list to

theapplication.

Line 11 -

List the local governments where you have a business license. If additional space is needed attach a list to the applica

tion.

FEE SECTION

"Failure to apply for a Master License will result in the imposition of a $125.00 penalty. Failure to order decals for machines will

result in the imposition of a $50.00 per machine penalty." Any violation of this law can result in suspension or revocation of

your license, seizure of equipment, and debarment for repeat offenders. Equipment can be sold at public auction after 30 days'

advertisement. The Revenue Commissioner will charge a fee of $75.00 for the release of any machine that has been sealed.

If you apply for a six (6) months' license that expires before the end of the calendar year, you must reapply if you decide to stay in

business for the rest of the calendar year. At that time another license fee is due. Annual Licenses and all decals expire December

31. License fees are not prorated.

When applying for a duplicate of your original license you MUST attach an affidavit, showing the REASON that you need a

duplicate(e.g., lost license).

The 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.

SIGNATURE SECTION

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 ofthis application for your file.

GEORGIA DEPARTMENT OF REVENUE

REGISTRATION UNIT

P. O. BOX 38428

ATLANTA, GEORGIA30334-8428

Please allow one week for processing. For further information call (404) 656-1793.

IMPORTANT NOTICE: Your permits will not be issued if there are any outstanding liabilities against your account. Stickers

must be affixed to the machine

Form Crf-013 - Instructions For Completion Of The Coin Operated State Amusement Machine Application

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