Additional Ownership-Relationship Form
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Additional Ownership-Relationship Form. This is a Georgia form and can be use in Department Of Revenue Statewide.
Loading PDF...
Tags: Additional Ownership-Relationship Form, CRF-004, Georgia Statewide, Department Of Revenue
CRF-004 (Rev. 2/08)
GEORGIA DEPARTMENT OF REVENUE
REGISTRATION and LICENSING UNIT
P. O. BOX 49512
ATLANTA, GA 30334-8428
Phone: 404-417-4490
Fax: 404-417-4317 or 404-417-4318
TSD-sales-tax-lic@dor.ga.gov
TSD-withholding-lic@dor.ga.gov
ADDITIONAL OWNERSHIP / RELATIONSHIP FORM
(Complete Only If Necessary)
(PLEASE PRINT OR TYPE)
FOR OFFICE
USE ONLY
LEGAL BUSINESS NAME:
A
CHECK ALL THAT APPLY
Owner
%
Member
%
BUSINESS NAME
B
GA. SALES TAX NO.
C
LAST NAME
D
CITY
/
/___
__
ADDRESS
E
EFFECTIVE DATE
Manager
%
%
Alcohol Licensee
STI or LICENSE NO.
Officer
%
Tobacco Licensee
Partner
%
Managing Member
%
%
GA. WITHHOLDING TAX NO.
FIRST NAME
STATE
M.I.
ZIP
TITLE
SOCIAL SECURITY NO.
COUNTY
COUNTRY
PHONE
(
A
CHECK ALL THAT APPLY
Owner
%
Member
%
BUSINESS NAME
B
GA. SALES TAX NO.
C
LAST NAME
D
CITY
/___
__
ADDRESS
E
/
EFFECTIVE DATE
Manager
%
%
Alcohol Licensee
STI or LICENSE NO.
)
Officer
%
Tobacco License
Partner
%
Managing Member
%
%
GA. WITHHOLDING TAX NO.
FIRST NAME
STATE
M.I.
ZIP
TITLE
COUNTY
SOCIAL SECURITY NO.
COUNTRY
PHONE
(
A
CHECK ALL THAT APPLY
Owner
%
Member
%
BUSINESS NAME
B
GA. SALES TAX NO.
C
LAST NAME
D
CITY
/___
__
ADDRESS
E
/
EFFECTIVE DATE
Manager
%
%
Alcohol Licensee
STI or LICENSE NO.
)
Officer
%
Tobacco Licensee
%
Partner
%
Managing Member
%
GA. WITHHOLDING TAX NO.
FIRST NAME
STATE
M.I.
ZIP
TITLE
COUNTY
SOCIAL SECURITY NO.
COUNTRY
PHONE
(
)
SIGNATURE SECTION
I HAVE EXAMINED THIS FORM, AND TO THE BEST OF MY KNOWLEDGE IT IS TRUE AND CORRECT.
Signature
Title
Date
(MUST BE SIGNED BY OWNER, PARTNER, OR CORPORATE OFFICER AS LISTED IN THE RELATIONSHIP SECTION ABOVE.)
American LegalNet, Inc.
www.FormsWorkflow.com
