Additional Ownership-Relationship Form {CRF-004}

Print CRF-004 (Rev. 6/17/15) GEORGIA DEPARTMENT OF REVENUE REGISTRATION and LICENSING UNIT P. O. BOX 49512 ATLANTA, GA 30359-1512 Phone: 1-877-GADOR11 (1-877-423-6711) TSD-sales-tax-lic@dor.ga.gov Clear TSD-withholding-lic@dor.ga.gov (PLEASE PRINT OR TYPE) ADDITIONAL OWNERSHIP / RELATIONSHIP FORM (Complete Only If Necessary) LEGAL BUSINESS NAME: CHECK ALL THAT APPLY Owner LLC Member BUSINESS NAME GA. SALES TAX NO. LAST NAME ADDRESS CITY CHECK ALL THAT APPLY Owner LLC Member BUSINESS NAME GA. SALES TAX NO. LAST NAME ADDRESS CITY CHECK ALL THAT APPLY Owner LLC Member BUSINESS NAME GA. SALES TAX NO. LAST NAME ADDRESS CITY STATE ZIP COUNTY PHONE NUMBER FIRST NAME M.I. TITLE % % Officer Tobacco Licensee % % STATE ZIP Effective Date : Partner Alcohol Licensee % % Other : _______________ COUNTY PHONE NUMBER FIRST NAME M.I. TITLE % % Officer Tobacco Licensee % % STATE ZIP Effective Date : Partner Alcohol Licensee % % Other : _______________ COUNTY PHONE NUMBER FIRST NAME M.I. TITLE % % Officer Tobacco Licensee % % Effective Date : Partner Alcohol Licensee % % Other : _______________ TAX ACCOUNT NUMBER GA WITHHOLDING TAX NO. SOCIAL SECURITY NO. TAX ACCOUNT NUMBER GA WITHHOLDING TAX NO. SOCIAL SECURITY NO. TAX ACCOUNT NUMBER GA WITHHOLDING TAX NO. SOCIAL SECURITY NO. 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