Georgia Purchaser's Claim for Sales Tax Refund Affidavit

Purchaser's Claim for Sales Tax Refund Affidavit
TSD_Purchaser's_Claim_for_Sales_Tax_Refund_Affidavit_ST 12-B
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ST-12B (Rev 9/14/20)

AFFIDAVIT FOR PURCHASER’S CLAIM FOR TAX REFUND
PLEASE RETAIN A COPY FOR FUTURE AUDIT

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 (If Purchaser does not have a tax
account number, provide Federal Employer Identification Number or
Social Security Number.)

Name of Dealer

Dealer’s Tax Account Number (if known)

Dealer’s Street Address

City

State

Date of
Purchase

1.

Invoice No.

Gross Amount
of Sale
Excluding Tax

Did you request a tax refund from the Dealer?

Zip Code

Exempt Portion
of Sale

Yes

Tax Paid by
Purchaser to
Dealer

Item or Service Purchased

No. If yes, on what date? _________________. If no, why not?________

____________________________________________________________________________________________________________________

2.
3.

____________________________________________________________________________________________________________________
a. Enclose a copy of your request; and
b. Enclose a copy of proof of mailing or proof of delivery.
Did the Dealer refund any tax to you?
Yes
No. If yes, how much? $_______________________
Did the Dealer act upon your request for refund in any way?
Yes
No. If yes, what did the Dealer do? _________________________

Under penalties of perjury, I swear or affirm that I have personal knowledge and understanding of the statements made in this claim for tax
refund. The facts given in the claim and affidavit are true, correct and complete to the best of my knowledge and belief. I further understand that false
statements could result in criminal prosecution as well as the repayment of any refunded tax, plus interest and penalties.

__________________________________________
Purchaser’s Signature

_____________________________________________________
Purchaser’s Name and Title (if applicable)

Subscribed and sworn to me, this _______ day of ____________________, __________.
Notary Signature: ______________________________________________________

[Notary seal]

Typed or Printed Name of Notary: _________________________________________
NOTARY PUBLIC
Mail to: Georgia Department of Revenue, 1800 Century Boulevard NE, 8th Floor, Atlanta, Georgia 30345-3205
Telephone: 1-877-423-6711

THIS AFFIDAVIT SHALL BE ATTACHED TO FORM ST-12 AND MADE A PART OF PURCHASER’S TAX REFUND CLAIM