COIN-OPERATED AMUSEMENT MACHINE APPLICATION CRF-013 (Rev. 03/03) OFFICE USE ONLY Total Amount Received $ GEORGIA DEPARTMENT OF REVENUE CENTRALIZED TAXPAYER REGISTRATION UNIT P. O. BOX 49512 ATLANTA, GA 30359-1512 (404) 417-4490 Master License Number 1. (FORM CRF-002 MUST BE COMPLETED BEFORE LICENSES AND DECALS CAN BE ISSUED) (PLEASE PRINT OR TYPE) IDENTIFICATION SECTION If you have a State Taxpayer Identifier (STI) Number, Enter it here: 1a. Enter you Federal Employer Identification Number (FEI 2. LEGAL BUSINESS NAME 3. PRIMARY LOCATION ADDRESS (number and street) 4. CITY 5. TYPE OF OWNERSHIP 2a. COUNTY DBA OR TRADE NAME (If applicable) STATE ZIP CODE +4 PHONE ( Proprietorship Partnership 6. Date you first plan to operate 7. Alcohol License Number Corporation ) Other (specify) AMUSEMENT MACHINE INFORMATION SECTION Will you renew you license next year? (Check one) 6a. YES NO Sales Tax Number 9. Withholding Tax Number 8. 10. To which local governments will you pay ad valorem tax? 11. Which local governments will be issuing your business license(s)? City Name(s) County FEE SECTION 12. LICENSE FEES: (Check the appropriate box(es) and return the total amount due with the application.) th FULL YEAR 6 MONTHS th LEVEL 1 LICENSE (1-5 Machines) Master License Fee - $250 (Plus $1250.00 if 6 -60 machine acquired during the year). Six (6) Month Master License Fee - $175 LEVEL 2 LICENSE (6-60 Machines) Master License Fee - $1,500 (Plus $1000.00 if 61 or more machines are acquired during the year). Six (6) Month Master License Fee - $1,050 LEVEL 3 LICENSE (61 or More) st Master License Fee - $2,500 Six (6) Month Master License Fee - $1,750 ANNUAL PERMIT STICKER FEE (Per Machine): $25 Sticker must be affixed to the machine. $50.00 PENALTY FEE: (Per machine) Machine in operation without a sticker affixed. DUPLICATE ORIGINAL LICENSE FEE -$100 (notarized affidavit must be attached) FAILURE TO PAY TIMELY MASTER LICENSE FEE - $125 PENALTY TO RELEASE SEIZURE OF MACHINE - $75 per machine. TOTAL FEES DUE No REFUND of any of these fees is authorized if owner ceases operation prior to the end of the calendar year. MAKE CHECK PAYABLE TO THE “ GEORGIA DEPARTMENT OF REVENUE”. GEORGIA LAW STIPULATES THAT TAXES AND FEES SHALL BE PAID IN LAWFUL MONEY OF THE U.S. FREE OF EXPENSE TO GEORGIA. SIGNATURE SECTION THIS APPLICATION HAS BEEN EXAMINED BY ME AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. Signature Title Date (Must be signed by owner, partner or authorized officer of corporation. Stamped signature is not acceptable.) American LegalNet, Inc. www.FormsWorkflow.com STATE OF GEORGIA DEPARTMENT OF REVENUE INSTRUCTIONS FOR THE COMPLETION OF THE COIN OPERATED STATE AMUSEMENT MACHINE APPLICATION (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. This pertains to completion of CRF-002. 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 of these officers, owners, or partners. INSTRUCTIONS FOR COMPLETING FORM CRF-013: A. IDENTIFICATION SECTION Line 1- Enter your Georgia State Taxpayer Identifier. (If you do not yet have one, leave blank.) (1a) Enter your Federal Employer Identification Number if applicable. Line 2- Enter your legal business name listed on Form CRF-002. (2a). Enter your DBA name from CRF-002. 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. B. 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 the next year? Line 7- Enter your State Liquor/Beer and/or 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 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 the application. Line 11- List the local governments where you have a business license. If additional space is needed, attach a list to the application. C. FEE SECTION “ Failure to apply for a Master License will result in the imposition of a $125.00 penalty. Failure to order and affix 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 per machine for the release of any machine that has been seized and sealed. No one is authorized to remove the seals after they are in place without written authorization from the Commissioner or his authorized agents after payment of penalties. 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. Licenses for six months or less expire six months from the date of issue or December 31, whichever comes first. 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, etc.). D. E. 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 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, with fees attached, to the address shown below. You should retain a copy of this application for your file. GEORGIA DEPARTMENT OF REVENUE CENTRALIZED TAXPAYER REGISTRATION UNIT P. O. BOX 49512 ATLANTA, GA 30359-1512 Please allow 4 to 6 weeks for processing. For further information, call (404) 417-4490. IMPORTANT NOTICE: Your permits will NOT be issued if there are any outstanding liabilities against your account(s). American LegalNet, Inc. www.FormsWorkflow.com