Form TSD-10 Fillable Form TSD-10 Application for Tax Clearance Certificate (eff. 1/1/07)
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

business attach a copy of the sales contract and financing agreement if any This form should only be used to request a clearance certificate for sales tax income tax withholding corporate income net worth tax (: Cash Sale) Unchecked (: Contract Sale) Unchecked (: Conventional Financing) Unchecked (: no1) Unchecked (: no2) Unchecked (: no3) Unchecked (: Other) Unchecked (: Real Estate Transaction) Unchecked (: Selling Business) Unchecked (: Yes) Unchecked (: Yes2) Unchecked (: Yes3) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (Clear) Clear (Print) Print (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) 1800 Century Blvd Suite 8238 Allow at least ten business days for processing of this form An owner or officer of the business requesting the tax clearance must complete this step If you have been appointed as power of APPLICATION FOR TAX CLEARANCE CERTIFICATE Atlanta GA 30345 attorney for the taxpayer you must attach a copy of your power of attorney (Form RD 1061) that specifically states your authorization City state ZIP Contract sale Conventional Date business started in Georgia: Date business was sold or is to be sold: Date: Title Department to send this tax clearance certificate to the purchaser listed Do you maintain an office in Georgia? yes noDo you have employees in Georgia? yes no Do you make retail sales in Georgia? yes no Doing business as Effective Date: 1/1/2007 Email: taxpayer services@dor ga gov Exempt organizations: Attach IRS determination letter latest relevant exempt organization return and Form 600 T (if required) Fax: (404) 417 6629 Federal Employer Identification No financing FOR OFFICE USE ONLY FORM TSD 10 General Information Georgia Department of Revenue Georgia Sales Tax Registration No (if applicable) Georgia State Tax Identifier No Georgia Withholding Tax Account No (if applicable) If you are completing this form because you are selling or have sold your business assets stock of goods or equipment or have quit the in Step 4 income tax and exempt organization UBIT Mail fax or email your completed form (and any applicable attachments) or questions to the applicable address or fax listed above Other Print or type name Purchasers address Purchaser's federal employer identification number Disclosure Authorization: Check this box if you authorize the Purchaser's Georgia State Tax Identifier No (if any) Purchasers name Real estate transaction Selling business assets (see step 4) Other Sales and use tax Income tax withholding Corporate income tax Corporate net worth tax Income Tax Selling price of business: Signature Signature of Notary Date NOTARY SEAL Social Security Number (if applicable) Step 1: Identify yourself or your business Step 2: Check the taxes for which you are requesting tax clearance Tax exempt organization and Step 3: Check the reason for which you are requesting tax clearance Step 4:Provide the following data if you are selling your business assets or otherwise quitting your business: Step 5: Sign below Street address SUT W/H Corp Taxpayer Services Division Telephone No Telephone: 1 877 423 6711 Terms of sale: Cash sale This form will not be processed until all returns are filed and balances due are paid in full (including penalty and interest if applicable) to request this tax clearance and receive all related correspondence from the Georgia Department of Revenue Unrelated Business