Form Tsd-10 - Application For Tax Clearance Certificate
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1FORM TSD-10
Georgia Department of Revenue
Taxpayer Services Division
Effective Date: 1/1/2007
1800 Century Blvd. Suite 8238
FOR OFFICE USE ONLY
Atlanta, GA 30345
Print
Clear
Telephone: 1-877-423-6711
SUT
____ W/H ____ Corp ______
Fax: (404) 417-6629
Email: taxpayer.services@dor.ga.gov
APPLICATION FOR TAX CLEARANCE CERTIFICATE
General Information
●
This form should only be used to request a clearance certificate for sales tax, income tax withholding, corporate income, net worth tax,
income tax, and exempt organization UBIT.
●
This form will not be processed until all returns are filed and balances due are paid in full (including penalty and interest, if applic able).
●
Allow at least ten business days for processing of this form.
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Mail, fax or email your completed form (and any applicable attachments) or questions to the applicable address or fax listed above.
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If you are completing this form because you are selling or have sold your business assets, stock of goods or equipment, or have quit the
●
business, attach a copy of the sales contract and financing agreement, if any.
●
Exempt organizations: Attach IRS determination letter, latest relevant exempt organization return, and Form 600-T (if required).
Step 1: Identify yourself or your business
Georgia State Tax Identifier No.
Name
Georgia Sales Tax Registration No. (if applicable)
Doing business as
Georgia Withholding Tax Account No. (if applicable)
Street address
Social Security Number (if applicable)
City, state, ZIP
Date business started in Georgia:
Telephone No.
yes
Do you make retail sales in Georgia?
no
yes
Do you maintain an office in Georgia?
no
Federal Employer Identification No
yes
Do you have employees in Georgia?
no
Tax exempt organization and
Step 2: Check the taxes for which you are requesting tax clearance
Unrelated Business
Sales and use tax
Income tax withholding
Corporate income tax
Corporate net worth tax
Income Tax
Step 3: Check the reason for which you are requesting tax clearance
Other
Real estate transaction
Selling business assets (see step 4)
Step 4:Provide the following data if you are selling your business assets or otherwise quitting your business:
Purchasers name
Date business was sold or is to be sold:
Selling price of business:
Purchasers address
Conventional
Terms of sale: Cash sale
Contract sale
financing
City
State
ZIP
Other
Purchaser's federal employer identification number
Disclosure Authorization: Check this box
if you authorize the
Department to send this tax clearance certificate to the purchaser listed
Purchaser's Georgia State Tax Identifier No.
(if any)
in Step 4.
Step 5: Sign below.
An owner or officer of the business requesting the tax clearance must complete this step. If you have been appointed as power of
attorney for the taxpayer, you must attach a copy of your power of attorney (Form RD-1061) that specifically states your authorization
to request this tax clearance and receive all related correspondence from the Georgia Department of Revenue.
Signature
Date:
Title
Print or type name
Signature of Notary
Date
NOTARY SEAL
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