Form It-Dn - Disaster Notification Page 2
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CLEAR
IT-DN (Rev. 6/14)
If the out-of-state business is an affiliate of a registered business in this state the above information
must be provided by the registered business for the affiliate and must also provide the following
information (note in the affiliate case the form only needs to be provided once to DOR):
Name of Registered Business: ________________________________
Principal Business Address (number and street, City or Town, State, and Zip Code):
________________________________________________________________
Federal Employer Identification Number: _____________
Contact Person Name: ____________________________
Contact Person Phone Number: ____________________
Contact Person email address: _____________________
I/we declare that the above named out-of-state business is in Georgia for the purposes of responding to
a declared disaster or emergency and meets the requirements of O.C.G.A. § 48-2-100 to be exempt.
I/we declare under the penalties of perjury that I/we have examined this form (including attachments)
and to the best of my/our knowledge and belief it is true, correct, and complete.
For the Out-of-State-Business
___________________________________________________ ________________________________
Signature of Officer
Date
Name and Title of Officer
For the Registered Business (if it applies)
___________________________________________________ ________________________________
Signature of Officer
Date
Name and Title of Officer
Please mail a copy of the form to the following address:
Georgia Department of Revenue
1800 Century Blvd NE
th
8
Floor
Atlanta, GA 30345
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