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Form Mf-12 - Waiver Of Seller'S Rights For Refund - Departament Of Revenue, State Of Georgia

MF-12 (Rev. 3/05)

DEPARTMENT OF REVENUE

Taxpayer Services Division

1800 Century Center Boulevard, NE, Ste. 8223

Atlanta, Georgia 30345-3205

Telephone: (404) 417-6710

WAIVER OF SELLER’S RIGHTS FOR REFUND

Name of Seller

Seller’s License Number

Name of Purchaser

Seller’s Street Address, City or Town, State and Zipcode

Tax Paid to

Exempt Portion

Date

Invoice No.

Gallons

Seller by

( If applicable)

Type of Fuel

Purchaser

AFFIDAVIT OF SELLER

The undersigned authorized representative of the above-named seller 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 motor fuel tax shown paid was collected from the above named purchaser and was

remitted to the Department of Revenue, and that this seller disclaims any interest in said motor fuel taxes remitted to the Department of Revenue and waives any

right to refunds due therefor.

This day of _________________,______.

______________________________________________

Seller

Subscribed and sworn to:

By: ___________________________________________

Name and Title

This ____ day of ____________,______.

_____________________________________

Notary Public

THIS WAIVER SHALL BE ATTACHED TO AND MADE A PART OF MOTOR FUEL TAX CLAIM OF PURCHASER