Form St-12b - Purchaser'S Claim For Sales Tax Refund Affidavit

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ST-12B (Rev 1/12)
Georgia Department of Revenue
Taxpayer Services Division
1800 Century Blvd. NE
Atlanta, GA 30345-3205
1(877) 423-6711
PURCHASER’S CLAIM FOR SALES TAX REFUND AFFIDAVIT
PLEASE RETAIN A COPY FOR FUTURE AUDIT
Name of Purchaser
Purchaser’s Sales Tax Number (if Purchaser does not have a Sales Tax
Number, provide Federal Employer Identification Number or Social
Security Number)
Dealer’s Sales Tax Number (if known)
Name of Dealer
Dealer’s Street Address
City
State
Zip Code
Date of
Invoice No.
Gross Amount
Exempt Portion
Tax Paid by
Item Purchased
Purchase
of Sale
of Sale
Purchaser to
Excluding Tax
Dealer
1.
Did you request a sales tax refund from the Dealer?
Yes
No. If yes, on what date? ____________________. If no, why not?________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
a.
Enclose a copy of your request; and
b.
Enclose a copy of proof of mailing or proof of delivery.
2.
Did the Dealer refund any sales tax to you?
Yes
No. If yes, how much? $_______________________
3.
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 sales tax claim for
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
THIS AFFIDAVIT SHALL BE ATTACHED TO FORM ST-12 AND MADE A PART OF PURCHASER’S SALES TAX CLAIM FOR REFUND

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