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Additional Ownership-Relationship Form CRF-004 - Georgia

Additional Ownership-Relationship Form Form. This is a Georgia form and can be used in Alcohol And Tobacco Division Department Of Revenue Statewide .
 Fillable pdf Last Modified 3/24/2010
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CRF-004 (Rev. 5/05) GEORGIA DEPARTMENT OF REVENUE REGISTRATION UNIT P. O. BOX 49512 ATLANTA, GA 30334-8428 404-417-4490 TSD-sales-tax-lic@dor.ga.gov (PLEASE PRINT OR TYPE) ADDITIONAL OWNERSHIP / RELATIONSHIP FORM (Complete Only If Necessary) FOR OFFICE USE ONLY LEGAL BUSINESS NAME: C HE C K AL L T HAT AP P L Y Owner Partner B U S IN E S S N A ME G A. S AL E S T AX NO . LAST NAME ADDRESS C IT Y S T AT E Z IP C O UNT Y C O UNT R Y P HO NE FIRST NAME M.I. O cer Managing Member E F F E C T I V E D A T E ___ Alcohol Licensee Tobacco Licensee S T I or L I C E N S E N O . / _____ /___________ Related Business Parent Company A B C D E G A . W IT H H O L D IN G T A X N O . TITLE SOCIAL SECURITY NO. ( C HE C K AL L T HAT AP P L Y Owner Partner B U S IN E S S N A ME G A. S AL E S T AX NO . LAST NAME ADDRESS C IT Y S T AT E Z IP C O UNT Y C O UNT R Y FIRST NAME M.I. O cer Managing Member ) A B C D E E F F E C T IV E D A T E ____/ _____ /___________ Alcohol Licensee Related Business Tobacco Licensee Parent Company S T I or L I C E N S E N O . G A . W IT H H O L D IN G T A X N O . TITLE SOCIAL SECURITY NO. P HO NE ( CHECK ALL THAT APPLY Owner Partner B U S IN E S S N A ME G A. S AL E S T AX NO . LAST NAME ADDRESS C IT Y S T AT E Z IP C O UNT Y C O UNT R Y FIRST NAME M.I. EFFECTIVE DATE O cer Shareholder ) / Alcohol Licensee Tobacco Licensee S T I or L I C E N S E N O . G A . W IT H H O L D IN G T A X N O . / Related Business Parent Company A B C D E TITLE SOCIAL SECURITY NO. P HO NE ( SIGNATURE SECTION ) I HAVE EXAMINED THIS FORM, AND TO THE BEST OF MY KNOWLEDGE IT IS TRUE AND CORRECT. Signature (MUST BE SIGNED BY OWNER, PARTNER, OR CORPORATE O Title Date FFICER AS LISTED IN THE RELATIONSHIP SECTION ABOVE.) American LegalNet, Inc. www.FormsWorkflow.com
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