Form Mv-6 - Dealer, Distributor, Manufacturer & Transporter Tag Application Page 3

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Form MV-6B (Revised 04-2013)

Georgia Department of Revenue - Motor Vehicle Division

Dealer, Distributor, Manufacturer or Transporter Application for Additional Tags

Please read the instructions that apply to

requested tag cate

gory before

completing and submitting documents and fees.

Permanent Twelve-Digit (12) Customer ID Number

urrent Master Tag Number

Company’s Publicly Listed Phone (No cell phone numbers)

tate of Georgia Tax ID Number

Full, Legal Name of Company, Business, Firm, Corporation, LLC

D/B/A Company, Business, Firm, Corporation, LL

C Name under which you do

usiness if not

the same as the full, legal name

Established Place of Business Street Address

City

State

Zip Code

County

Mailing Address (if different from street address)

City

State

Zip Code

County

Tag Category

Check box to indicate the tag category for which you are requesting additional tags.

Dealer

Distributor

Manufacturer

Motorcycle Dealer

Motorcycle Distributor

Motorcycle Manufacturer

Tran

sporter

When applying for dealer tags, check applicable box below:

Fees

Franchise Dealer (new motor vehicles)

umber of additional tags* ________@$12.00

$__________

Independent Dealer (used motor vehicles)

Mailing Fee*

_________# of ta

$__________

An Independent Dealer must also check the applicable box(s) below:

TAL DUE

$__________

Auction Company

oker

Retail Dealer

Wholesaler

Motorcycle Dealer

*See instructions for requirements. Pay all fees with one check or money order

payable to the Department of Revenue. Please do not remit cash through the

Manufactured Home Dealer

mail!

Trailer Dealer

Affidavit

I, ___________________________________________________________________, am applying for __________________________________

(Authorized Agent’s Printed Name & Position or Job Title)

(Number of Additional Tags)

additional tags. To be eligible to receive more than two (2) additional tags, I am completing the following affidavit certifying the number of

vehicles the business named in this application sold (retail or wholesale), distributed, manufactured or transported during the previous calendar

year based on its business records. If the business named in this application is a new business or has been in business less than a year, I am

certifying the number of vehicles the business is projected to sell (retail or wholesale), distribute, manufacture or transport during the coming

calendar year. I understand that the Department has the right to limit the number of additional tags issued when the numbers certified in this

affidavit differs from the department’s records, business records or investigative findings. I also understand that the Department may request

additional documents to validate the need for additional tags.

Check the applic

able b

Actual Number

Projected Number

No. of Additional Tags

Reta

il V

ehicle Sales

Vehicles Distributed, Manufactured or Transported

Broker/Wholesaler/Auction Sales

Requested

Number Sold Retail:

No. Distributed, Manufactured or Transported:

No. Brokered, Wholesaled or S

old

at Auction:

I hereby swear, affirm or certify under criminal penalty of a felony for fraudulent use of a false or fictitious name or address or making a material

false statement punishable by a fine of up to $5,000 or by imprisonment of up to five (5) years, or both, that statements contained on documents

submitted by me are true and accurate and I understand the authorized uses of these tags as required by this state’s laws, rules and regulations.

I understand that I must promptly file a police report when a tag is lost or stolen and submit a copy of such police report to the Motor Vehicle

Division. I further swear, affirm or certify that in accordance with §40-3-33 (b) of Georgia La

w, my rec

ords shall be available for inspection by

any representative or officer of the Department of Revenue upon request during normal busines

s hours.

Signature & Position/Job Title of Person Authorized to Complete MV-6, MV-6A, MV-6B & MV-6C Forms:

Sworn to and subscribed before me this _________ of ___

_________________, 2________.

(day)

(Month)

(Year)

Notary Public’s Printed Name, Signature & Notary Seal or Stamp:

Date N

otary Public’s Commission Expir

es:

Mailing Address

In-Person Address

ATTN: Dealer Registration

Department of Revenue

DOR/Motor Vehicle Division

Motor Vehicle Division

PO Box 740381

4125 Welcome All Road

Atlanta, Georgia 30374-0381

Atlanta, Georgia 30349

If you need additional information, please call 1-855-406-5221. You can electronically complete & print these forms for signing & submission from our website,

etax.dor.ga.gov.

E-mail:

dealer.tags@dor.ga.gov