APPLICATION LAMAR COUNTY OCCUPATIONAL TAX & LICENSE, LAMAR COUNTY ZONING ADMINISTRATION 4408 THOMASTON STREET, SUITE B BARNESVILLE, GEORGIA 30204 PHONE NUMBER: 770-358-5364 FAX NUMBER: 770-358-5821 BUSINESS NAME: OWNER: BUSINESS ADDRESS: MAILING ADDRES! ‘TELEPHONE NUMBER: DATE ESTABLISHED: BUSINESS PURPOSE: For all paris engaged ino carrying on busines inthe unincorporated aren of Lamar County, ‘ccpational Lense tax shall be levied on all business and practitioners of profesio ccupatons wih one or more lotions andlor offies in the unnebrporated area of Lamar County ‘Ai Besinesses with more than 10" employees must submit an Annual Compliance Report on ‘Occupation Taxes (Busines Licenses) that Includes an E-Verlfy mumber (hp. dhsgovie verity. Using the lst below, compute your tax amount, +#*Total # of Employees "=**Occupational Tax for # of Employees 1-9 (inchudes Business Owner) $50.00 099 75.00 100-499" 3150.00 mF $250.00 Number of Employees: ‘Tax Identification # Social Security #:, 5 +320.00 = 5, License Fee (Admin, Fee) Total Tax Fee Due LATE FEE: ADD 10% TO “TOTAL TAX FEE DUE” AFTER MARCH 31° ‘ADD 15% AFTER APRIL 30" / ADD 20% AFTER MAY 31 ADD 25% AFTER JUNE 30™ ‘*+4ection below to be filled in by Lamar County Tax Offic ‘Has applicant filed a current Personal Property Return? ___Yes __No ‘Tax Assessor's Initials Are all taxes current? Yes No “Tax Comm. Initials +++] certify that all information Is true and correct. ‘Siguature of Applicant Date [NOTE: With yur application, lease submit the busines lcense fe as you have computed Upon ‘recip, your Busines license wil be mailed to you within 7 business days. Please make checks payable to Lamar Count. Ifa rate lenses required, plese encose a copy. Yowr busines lense ‘wnat be processed, and business not be conducted unl proof of holding a required state ‘sins lease Is eclved.Private Employer Exemption Affidavit Pursuant To 0.C.G.A. Section 36-60-6(d) By executing this afidavit, the undersigned private employer verifies that it is exempt from ‘compliance with O.C.G.A, Section 36-6046, stating affirmatively that the individual, firm or corporation employs ten (20) employees o less and therefore, is not required to register with and/or utlize the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in 0.C.G.A Section 13-10-90, Signature of Exempt Private Employer” Printed Name of Exempted Private Employer I hereby declare under penalty of perjury thatthe foregoing is true and correct. Executed on __ 201_ In Barnesville, Georgia Signature of Authorized Officer or Agerit Printed Name and Title of Authorized Oificer/Agent ‘SUBSCRIBED AND SWORN BEFOR ME ON THIS THE DAY Of seca 204 {NOTARY PUBLIC) My Commission Expires: