ACCOUNT CLOSURE FORM
*ALL FIELDS ARE REQUIRED*
INCOMPLETE OR ILLEGIBLE FORMS WILL NOT BE PROCESSED
CURRENT BUSINESS INFORMATION ON FILE
Account Number or Certificate Number:
Complete Business Name (DBA):
Business Location Address:
REQUESTED MAILING ADDRESS
What date did your business close? (MM-DD-YYYY):
What was your FINAL GEORGIA GROSS REVENUE at this location, from January 1
through the date that
your business closed?: $
I certify that I am a Sole Owner/President/CEO/Managing Member/Majority Partner of the above
mentioned business, and authorized to make changes to and/or close this account. In addition, I certify
the above information is true and correct and contains no false or fraudulent information.
Signature of Authorized Person Completing Form:
Printed Name of Authorized Person Completing Form:
Please retain a copy of this form for your records.
You will not receive an additional confirmation that the account has been closed.
Please mail completed form to: GWINNETT COUNTY LICENSE & REVENUE
P.O. BOX 1045
LAWRENCEVILLE, GA 30046