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Temporary Location Permit Coin Operated Amusement Machine Application ATT-300TLP - Georgia
| Temporary Location Permit Coin Operated Amusement Machine Application Form. This is a Georgia form and can be used in Alcohol And Tobacco Division Department Of Revenue Statewide . |
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ATT-300TLP (Rev. 2/12) TEMPORARY LOCATION PERMIT COIN-OPERATED AMUSEMENT MACHINE APPLICATION OFFICE USE ONLY TOTAL AMOUNT RECEIVED $ ______________________ LOCATION LICENSE NUMBER Georgia Department of Revenue ATD-COAM P.O. Box 105458 Atlanta, Georgia 30348-5458 (404) 417-4900 ATDIV@dor.ga.gov (PLEASE PRINT OR TYPE) IDENTIFICATION SECTION 1. STATE TAXPAYER IDENTIFIER (STI) NUMBER 1a. FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) 2. LEGAL BUSINESS NAME 2a. DBA or TRADE NAME (if applicable) 3. PRIMARY LOCATION ADDRESS (number and street) 3a. EMAIL ADDRESS 4. CITY COUNTY STATE ZIP CODE+4 PHONE ( 5. Dates of Operation May NOT exceed seven (7) days LICENSE PERIOD START DATE LICENSE PERIOD END DATE 7. CITY COUNTY ) 6. ADDRESS OF TEMPORARY LICENSE LOCATION (number and street) STATE ZIP CODE+4 PHONE ( MASTER LICENSE AND PAYMENT SECTION 8. Master License Numbers Displayed at location: 9. Number of Class A Machines Per License 9a. Class A - $25 fee for each machine ) Total Payments 10. Number of Class B Machines Per License 10a. Class B -$125 fee for each machine Total Fees for Location License Processing Cost for Location License $ $ $ 50.00 TOTAL PAYMENT DUE No REFUND of any of these fees is authorized if owner ceases operation prior to the end of the license period. 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 Under penalty of law, I declare this application has been completed or throughly examined by me and is true and correct. (Signature) (Title) (Date) (Must be signed by the owner, partner or authorized officer of the corporation. Stamped signature is not acceptable.) SEE REVERSE SIDE FOR ADDITIONAL INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com ATT-300TLP (Rev. 2/12) INSTRUCTIONS FOR THE COMPLETION OF THE COIN OPERATED STATE AMUSEMENT MACHINE APPLICATION (FORM ATT-300 TLP) TYPE OR PRINT IN INK DO NOT USE PENCIL STATE OF GEORGIA DEPARTMENT OF REVENUE 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. INSTRUCTIONS FOR COMPLETING FORM A TT- 3 00 T LP : A. IDENTIFIC ATI ON SECTION Line1 1a Line 2 2a Line 3 3a Line 4 Line 5 Line 6 Line 7 - Enter your Georgia Taxpayer Identifier (STI). If you do not have one, leave blank. - Enter your Federal Employer Identification Number (FEIN), if applicable. - Enter your legal business name listed on Form CRF-002. - Enter your DBA name from Form CRF-002. - Enter the physical location address of your business. (A Post Office Box or PMB is not an acceptable location address). - Enter your business email address. - Enter your business city, county, state, zip code and phone number. - Enter dates for which you plan to operate temporarily in Georgia Line. - Enter the address of temporary location where machines will be operated. - Enter city, county, state, zip code and phone number. B. Line 8 Line 9 Line 9a Line 10 Line 10a MASTER LICENSE AND PAYMENT SECTION -Enter Master License Numbers for each amusement machine at your location. -Enter the number of Class A machines per master license. -Enter the payment amount (number of Class A machines * $25.00). -Enter the number of Class B machines per master license. -Enter the payment amount (number of Class B machines *125.00). (If applicable, add columns 9a and 10a into total Payments box.) Enter all other applicable fees/cost. Enter the TOTAL PAYMENT DUE. C. FEE SECTION Failure to apply for a Temporary Location Permit will result in the imposition of a $125.00 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. When applying for a duplicate license you must attach an affidavit, showing the reason that you need a duplicate (e.g., lost license, etc.). D. E. SIGNATURE SECTION 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. 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 ATD-COAM P. O. BOX 105458 ATLANTA, GA 30348-5458 Please allow 4 to 6 weeks for processing. For further information, call (404) 417-4900. IMPORTANT NOTICE: Your permits will NOT be issued if there are any outstanding liabilities against your account(s). INSTRUCTIONS FOR M AILI NG: This application must be signed by the owner, a partner, or an authorized officer of the corporation. American LegalNet, Inc. www.FormsWorkFlow.com
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