CITY OF RICHMOND HILL
APPLICATION FOR BUSINESS OCCUPATIONAL TAX CERTIFICATE
Certificate Year _______
Full Physical Address of Business (No PO Box)
Business Telephone Number
Full Business Mailing Address
List Names of Owner(s), Partners, or Officers (Attach Separate Sheets if Necessary)
Name Date of Birth Phone Number Residence Address SSN Title
Date business commenced in incorporated City of Richmond Hill, GA
Does this business require a State of Georgia license?
If yes, provide expiration date
Provide description of primary business activity:
Is this a Home Occupation Business?
If yes, you must complete the “Home Business Affidavit”
***In order for your certifcate to be issued, submit the following documentation with your application and payment***
• IF applicable, submit a coy of your State of Georgia license
• IF you are a convenience store, submit a copy of the latest Dept. of Agriculture license
• IF you are a restaurant, submit a copy of your current Health Dept Inspection Grade Certificate
• IF you are engaged in a profession or business required to be licensed by the state under Title 43, you must provide
evidence of such licensure to the City of Richmond Hill
• IF you are a Home Occupation Business, you are required to complete and return the Home Occupaction Affidavit
• ALL applicants must submit the “Affidavit Verifying Status of Benefit Applicant”, this document must be notarized
• ALL applicants must submit the “Private Employer Affidavit”, this document must be notarized
• ALL applicants must submit a secure and verifiable document. For a full list of acceptable documents please visit the
Attorney General of Georgia’s website at http://law.ga.gov
The occupation business tax is based on the total gross receipts of the business. Complete below for computation of fees.
Gross Receipts: _______________ (-50,000.00) x ( ) rte * (50.00)
(Report gross receipts even if under $50,000 gross receipts under $50,000 will pay a base fee of $50.00)
The gross receipts reported must come from your most recnet filed IRS Fedreal Income Tax Return
The IRS Has issued a ruling that a dopy of your Federal Income Tax Return May be required to be attahced to your Business
Ocupational Tax Certificate Application. _____________ (Must Initial)
Professional Practitioners May Elect to pay a flat fee per practitioner instead of based
on Gross receipts.
Report # of Prfessional Practitioners __________ x $400.00
If per practitioner fee is chosen, please submit a separate application for each practitioner.
Subtotal of Fees Due from (Line 1 or Line 2)
Penalty of 10% due on April 1
st
Interest of 1% due monthly beginning on April 1
st
Administrative fee is due for ALL applications and renewals
Total Fees Due (Lines 3 through 6)
Financial Institutions minimum business tax due is $1,000.00
I hereby swear under penalty of perjury that the information reported on this worksheet is to the best of my knowledge true, correct and complete. I understand that the issuance of the occupational tax
certificate does not permit the business to operate unless the business is propertly zoned and in complaince with all applicable City of Richmond Hill and State of Georgia ordinances and regulations. I
understand tht if it is determined that my business certificate requires board certification. I must submit a copy of that board certifcation along with my renewal. I understand that failure to supply ALL
required and or applicable documentation could result in a delay of the issuance of my Business Certificate.
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