Georgia Waiver of Vendor's Rights For Refund

Waiver of Vendor's Rights For Refund 
Waiver of Vendor's Rights for Refund
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ST-12A (Rev. 10/15/24)

WAIVER OF VENDOR’S RIGHTS FOR REFUND
If you are required to submit your refund electronically, please attach the signed, notarized copy to your electronic submission.

Name of Purchaser

Purchaser’s Tax Account Number

Name of Vendor

Vendor’s Tax Account Number

Vendor’s Street Address, City or Town, State and Zip Code
Date

MM/DD/YY

Invoice No.

Gross Amount
of Sale
Excluding Tax

Exempt
Portion, if any,
of Sale

Tax Paid
To Vendor
By Purchaser

Item Sold

AFFIDAVIT OF VENDOR

The undersigned authorized representative of the above-named vendor does hereby certify under oath that the above figures are true and correct with
respect to its transactions with the above-named purchaser for the periods indicated, that the tax shown paid was collected from this purchaser and
was remitted to the Department of Revenue, and that this vendor disclaims any interest in said tax remitted to the Department of Revenue and waives
any right to refunds due therefor.

This day of _________________,______.

______________________________________________

Subscribed and sworn to:

By:___________________________________________

This ____ day of ____________,______.

Vendor

Name and Title

_____________________________________
Notary Public

Mail to: Georgia Department of Revenue, Taxpayer Services Division 2595 Century Parkway NE, Suite 317, Atlanta, GA 30345-3173
Telephone: 1-877-423-6711
THIS WAIVER SHALL BE ATTACHED TO AND MADE A PART OF PURCHASER’S TAX REFUND CLAIM