Fillable 20__ RENEWAL APPLICATION for OCCUPATIONAL TAX CERTIFICATE (OTC) (Revize)

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20__ RENEWAL APPLICATION for OCCUPATIONAL TAX CERTIFICATE (OTC) (Revize)

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1
3725 Park Avenue Doraville, Georgia 30340
770.451.8745 Fax 770.936.3862
www.doravillega.us
20__ RENEWAL APPLICATION for OCCUPATIONAL TAX CERTIFICATE (OTC)
For renewals with NO change in location, ownership, or name of business.
Business Name:
Business Address:
City: _________________ State: ______ Zip: __________
Description: ____________________________________________________________________
Owner: __________________________________________________ NAICS Code: _________________
This application is for OTC renewals with NO change in location, ownership, or name of business. Any changes to location, ownership
or name of business will require a new OTC application. Renewal applications are accepted beginning January 1 of the renewal year
and are due by March 31 of the renewal year. Late applications are subject to penalties and interest. No renewals are accepted after
June 30. Businesses failing to renew by June 30 of the renewal year are required to submit an application for a new OTC and are
subject to penalties and interest.
All required information described below must be received to begin to process your OTC renewal.
Completed Renewal Application for OTC
Copy of applicant’s State- or Federally-issued Photo ID
If license is required by State of Georgia, copy of Individual or Business State License
Copy of DeKalb County Board of Health Food Service Permit for food service/preparation establishments
Copy of Georgia Department of Agriculture Food Sales Establishment License for food sales/processing establishments
Copy of DeKalb County Department of Watershed Management F.O.G. Certificate (Fats, Oils, and Greases Wastewater Discharge
Permit) for food service establishments
Occupational Tax Payment with Application
Your Occupational Tax calculation is based on your number of employees or gross receipts, whichever is higher. Alternatively,
eligible applicants may opt to use the flat fee calculation. Renewal applications must be received in person at Doraville City Hall,
3725 Park Avenue, Doraville, GA 30340, or by mail. No personal checks are accepted. Cashier’s checks or money order should be
payed to “City of Doraville”. There is a $4 credit card processing fee for those paying by credit card in person.
Occupational Tax Calculation
Line 1 – ACTUAL Number of Employees in 2021:
X
$ 35.00
=
$
Rate per Employee
X
$
=
$
Total Gross Receipts
Tax Rate (see chart above)
Line 2 – ACTUAL 2021 Gross Receipts: $
Enter total from line 1 or line 2 (whichever is greater): $
+
$ 50.00
=
$
Total Tax Due
Application Fee
Total Due
I elect to pay a flat fee in lieu of reporting gross receipts and paying a tax based on gross receipts. (400 Club Members ONLY)
Flat Rate:
$ 400.00
=
$
Number of Professionals
Flat Rate per professional
Total Due
I understand that: Individuals, businesses and practitioners who fail or refuse to make a timely or truthful tax return or make available truthful and
accurate information the City requests or requires for determining applicability or amount of occupation tax, or for levying or collecting such
occupation tax shall be subject to the imposition by the City of Doraville Municipal Court of a fine per Code Sec. 6-611. Individuals, businesses and
practitioners doing business in the City shall submit to the City Clerk, or his or her designee, or make available to the City within thirty (30) days such
information as may be required or requested by the City to determine the applicability and amount of the occupation tax or to facilitate levying or
collecting the occupation tax per Sec. 6-608(c).
I do solemnly swear or affirm that I have answered all questions truthfully and understand that any false statements made on this return may result
in revocation of the Occupational Tax Certificate issued by the City of Doraville.
Owner or Officer’s Signature
Revised 12/2021
Printed Name
Date
This application is for administrative use in determining occupational taxes only.
It does not grant any rights to operate a business contrary to any City ordinances, including zoning ordinances.
PLEASE TYPE OR PRINT CLEARLY – INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED
Number of Employees (min. of one)
EMAIL: __________________________
PHONE: _________________________
FEIN: __________________
businessservices@doravillega.us
*The first two digits of NAICS code determine class/rate
Class 1 .0003 42-44-45-62-56-23
Class 2 .0004 81-22-48-49-72-54
Class 3 .0005 52-11-31-33-71-61
Class 4 .0006 21-53-55-51
Revised 12/2021
2
AFFIDAVIT VERIFYING STATUS FOR CITY PUBLIC BENEFIT APPLICATION
By executing this affidavit under oath, as an applicant for a City of Doraville, Georgia Business License or Occupational Tax
Certificate, Alcohol License, Permit or other public benefit as referenced in O.C. G. A. Section §50-36-1, I am stating that following
with respect to my application for (check one) Occupation Tax Certificate, Alcohol License, Permit or other public benefit
for: [Name of natural person applying on behalf of individual, business, corporation, partnership or
other private entity]
I am a United States citizen, OR
I am a legal permanent resident 18 years of age or older or I am an otherwise qualified alien or non-immigrant under
the Federal Immigration and Nationality Act 18 years of age or older and lawfully present in the United States.
*Copy of Alien Registration Card
In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious
or fraudulent statement or representation in an affidavit shall be guilty of a violation of Code Section 16-10-20 of the Official Code
of Georgia.
Applicant Signature: _____________________________________________________Date: _____ / _____ / ________
*Must be signed in the presence of a Notary
*
Alien Registration Number for Non-Citizens
PRIVATE EMPLOYER AFFIDAVIT OF COMPLIANCE PURSUANT TO O.C.G.A. § 36-60-6(d)
By executing this affidavit, the undersigned private employer verifies its compliance with O.C.G.A. § 36-60-6, stating affirmatively
that the individual, firm or corporation employs more than ten employees and has registered with and utilizes 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 O.C.G.A. § 13-10-90. Furthermore, the undersigned private employer hereby attests that its
federal work authorization user identification number and date of authorization are as follows:
__________________________________________ _____________________________________ _____ / _____ / ______
FEDERAL WORK AUTHORIZATION USER IDENTIFICATION NUMBER NAME OF PRIVATE EMPLOYER DATE OF AUTHORIZATION
I hereby declare under penalty of perjury that the foregoing is true and correct.
Executed on this the _______ day of ___________________, 20_____ in ____________________________________, ______.
CITY STATE
________________________________________________ ___________________________________________________
SIGNATURE OF AUTHORIZED OFFICER OR AGENT PRINTED NAME AND TITLE OF AUTHORIZED OFFICER OR AGENT
*Must be signed in the presence of a Notary
SUBCRIBED AND SWORN BEFORE ME
ON THIS______ DAY OF______________ _______, 20_____
NOTARY PUBLIC
My commission expires: _____________________ (Seal)
STAFF USE ONLY
DATE
NOTES
Complete Application Received:
Application Fee Paid: $
Occupational Tax Paid: $
Documents/Licenses Required:
○ Food Services
○ State License
○ ID
OTC Issued: #
○ Pickup
○ Mailed
SAVE Response: ○ PRC ○ EAC ○ other
○ Lawfully Permitted
○ Require additional verification
*Notes:
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20__ RENEWAL APPLICATION for OCCUPATIONAL TAX CERTIFICATE (OTC) (Revize)

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Completed 25 February 2022

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