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Augusta-Richmond County License Department PO Box 9270 (1815 MARVIN GRIFFIN ROAD) Augusta, GA 30916-9270 Phone: [PHONE REDACTED] BUSINESS TAX RETURN COUNTY OF RICHMOND, BUSINESS TAX DIVISION Calendar Year 2009 Zoning Map & Parcel ith Ball Point Pen Account # FBB SIC Code Month Date Circle One Final Sold or Closed Business Date ) i ith the l No Business in the Home Business Name Zip Code Mailing Information Name Zip Code Previous Business Name and Location Name Zip Code Circle One Zip Code for Service of Business Name Zip Code Name Residence Address SSN Zip Code Name Officer Title SSN Zip Code Name Officer Title SSN Zip Code Name Officer Title SSN Zip Code ( Y N ) Existing Building ( Y or N ) ith Phone: i i FAX # [PHONE REDACTED] FOR BUSINESS LICENSE OFFICE USE ONLY Report Change in Location/Mailing Address to Business Tax Division Interviewed By: Please Type or Print w Tax Class Approved By: Complete all spaces as they relate to County Activity Day Year Started New Business Renewal Amended New YEARLY TOTAL GROSS RECEIPTS (EVEN DOLLARS Professionals and certain practitioners have the option of pay ng $330 per practitioner in lieu of reporting gross receipts. Check w Business Tax Office to determine eligibility for this option. Mobile On y – Business Location in County – Street Address (Not P.O. Box) City, State Mailing Address – Street or P.O. Box City, State Street – Not P.O. Box City, State Partnership Sole Ownership Corporation Principal Office, Corporate Name Street or P.O. Box City, State Officer, Agent or Attorney Affairs in County Street or P.O. Box City, State Name of Owner(s) & Street or P.O. Box City, State Street or P.O. Box City, State Street or P.O. Box City, State Street or P.O. Box City, State New Structure or CERTIFICATION: The information herein as required by Richmond County Code Part II, Chapter 8, Section 6-27.1 I, (Title) of the business firm named, do hereby register to operate said business w dominant business activity of (explain type of business) (Bus) (Res) State ID Number Federal ID Number In accord w th the Business Ordinance of Richmond County, Georgia, I, the undersigned, certify that I am the person duly authorized by the business herein named to file this return, including the accompany ng schedules and statements and that the same are true, correct, and complete. Applicant Signature Date