Form Att 300B – Fill Out and Use This PDF

ATT-300B (Rev. 2/12)

STATE OF GEORGIA

DEPARTMENT OF REVENUE

INSTRUCTIONS FOR THE COMPLETION OF COIN-OPERATED AMUSEMENT MACHINE REGISTRATION APPLICATION

(FORM ATT-300 A/B)

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 tables, and every coin-operated machine of any kind which provides music, such as juke boxes. For further information, refer to Georgia Codes 48-17-1 through 48-17-14.

This form can be used as a COAM renewal or initial registration application. When used as a renewal application the data is prepopulated in the correct fields on the front of the form. If being used as an initial registration application, form CRF-002 must be completed before licenses and/or decals can be issued. Also please follow instructions in the identification section below to complete this form. All other sections must be completed whether using this form as a renewal or initial registration application.

INSTRUCTIONS FOR COMPLETING FORM ATT-300 A/B:

A.IDENTIFICATION SECTION

Line 1- Enter your Georgia State Taxpayer Identifier (STI). (If you do not have one, leave blank) 1a - Enter your Federal Employer Identification Number (FEIN), if applicable.

Line 2 - Enter your legal business name listed on Form CRF-002. 2a - Enter your DBA name from Form CRF-002.

Line 3 - Enter the physical location address of your business. (A Post Office Box or PMB is not an acceptable location address). 3a - Enter your business email address.

Line 4 - Enter your business city, county, state, zip code and phone number. Line 5 - Enter the mailing street address.

Line 6 - Enter your mailing city, county, state, zip and phone number (if applicable).

B.PAYMENT SECTION

Line 7 - Enter the number of machines and all applicable fees and calculate totals.

-Enter all other applicable fees (a - h) for Master License A or all other application fees (a-g) for Master License B.

-Enter the TOTAL PAYMENT DUE.

*NOTE: Master License A upgrade calculation example: Enter master license fee on line 7a.	$2,000.00
Enter existing license fee credit on line 7c. -500.00
Enter TOTAL PAYMENT DUE	$1,500.00

License payments are not prorated.

Failure to timely apply for a Master License will result in the imposition of a $125.00 penalty. Failure to order and affix decals for Class A machines will result in the imposition of a $50.00 per machine penalty and a $250.00 per machine penalty for Class B. 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 authoriz- ation from the Revenue Commissioner or his authorized agents after payment of penalities.

NOTICE: Master License Processing Fee - The application processing fees is non-refundable. In the event a Master License is not issued; an additional processing fee of $200.00 will be assessed against the application and will be deducted from the license fee refund.

**NOTICE: In order to continue operating coin-operated music or amusement machines while their application is being processed and the background check is being conducted, and prior to the issuance of a Master License, the applicant may obtain a Tempo- rary License for an additional fee of $50.00. If applicable, please include the additional processing fee of the Temporary License in the proper space and in the Total Payment Due space on the application. Temporary License fees are non-refundable. After the issuance of a Temporary License, in the event a Master License is not issued: a processing fee of $200.00 in addition to the application processing fee, will be assessed against the Temporary License and will be deducted from the license fee refund.

When applying for a duplicate license you must attach an affidavit, showing the reason that you need a duplicate (e.g. lost license, etc.).

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.

C.SIGNATURE SECTION

This application must be signed by the owner, a partner, or an authorized officer of the corporation.

D.INSTRUCTION FOR MAILING

Mail the original application, with payment attached, to the address shown below. Please retain copies for your files.

GEORGIA DEPARTMENT OF REVENUE

ATD-COAM

POST OFFICE BOX 105458

ATLANTA, GEORGIA 30348-5458

Please allow 4 to 6 weeks for processing. For further information, call (404) 417-4900 IMPORTANT NOTICE: Your permit will not be issued if there are any outstanding liabilities against your account(s).