Georgia Sales Tax Claim for Refund

Sales Tax Claim for Refund
st-12.xps
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ST-12 (Rev. 09/14/20)

CLAIM FOR REFUND
Do not use this form if you are required to file electronic refund claims. Please review the electronic filing mandate
in Department of Revenue Rule 560-3-2-.26.
Refund claims must be filed with the Department within three years from the date the tax was paid. When the tax to
be refunded was paid to a vendor, the Claim for Refund (Form ST-12) must be accompanied by a properly completed
Waiver of Vendor's Rights (Form ST-12A) or an Affidavit for Purchaser's Claim for Tax Refund (Form ST-12B). When
the claimant has remitted tax directly to the Department, the ST-12A and ST-12B are not required. Please include all
supporting documents for the refund claimed, including invoices, proof of payment, sales journals, etc. Refund claims
received without supporting documentation may be delayed or denied.
__________________________________________________________________________________________________________________________________________________________________________________________________

Name of Taxpayer __________________________________________________________________________________
Address __________________________________________________________________________________________
City ______________________________________________________ State_______

Zip Code_________________

Contact Name __________________________________________________ Phone Number _______________________
Fax Number _______________________

Email Address __________________________________________________

Check the box to indicate who remitted the tax: Claimant [ ]

Vendor [ ]

Tax Type: Sales [ ] Use [ ] 911 Prepaid Wireless [ ] State Hotel-Motel-Fee [ ] Transportation Services Tax [ ]
Tax ID Number___________________________

(For The Applicable Tax Type Selected)

Amount Paid $ __________________________ Amount Claimed as Refund $ ___________________________

Period (s) of Claim_______________________________
Claimant verily believes that this claim should be allowed for the following reasons: (State in detail the factual and legal
basis of claim. Attach additional pages if necessary.)

I understand that to willfully file a claim for refund of taxes containing false information with the intent to defraud the state is
a crime under O.C.G.A. §48-1-6.
_____________________________________________

_____________________________________________

SIGNATURE OF CLAIMANT OR CLAIMANT’S AUTHORIZED AGENT

DATE

_____________________________________________

_____________________________________________

TITLE

(If attorney in fact, attach Power of Attorney Form RD-1061)

PRINTED NAME

Mail to: Georgia Department of Revenue, 1800 Century Boulevard NE, 8th Floor, Atlanta, Georgia 30345-3205
Telephone: 1-877-423-6711

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Page 2

ST-12 (Rev. 09/14/20)

ALLOCATION OF SALES & USE TAX (*For Sales or Use Tax Refund Claims Only*)
Instructions:
• You must break down your total sales/use tax refund claim amount (from page 1) into jurisdictions on this page. The amounts listed on this page
must equal the total refund claim amount.
• If you are claiming a refund of state sales and use tax, enter the claimed amount on Line 1.
• Use the remaining lines to write in your jurisdiction refund allocations and corresponding jurisdiction codes (one jurisdiction per line).
• For sales or uses occurring on or after April 1, 2018, do not use the City of Atlanta code 999. Use 044A to claim a refund of taxes imposed in the
City of Atlanta, DeKalb County. Use 060A to claim a refund of taxes imposed in the City of Atlanta, Fulton County.
• Attach additional copies of this page as needed.

Jurisdiction Name
1

STATE

Code
000

Jurisdiction Name

A. Refund Tax Amount

24

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46

Code

A. Refund Tax Amount