Form St-12 - Sales Tax Claim For Refund Page 2

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DEPARTMENT USE ONLY
AUDITOR CERTIFICATION
I certify that I have made an examination of the claim and facts submitted by the taxpayer and recommend that the amount indicated
herein be allowed and refunded.
Examining Auditor to complete items 1 through 8, including 5 if applicable, and the applicable tax distribution schedule
Period of Audit _______________________________________________________________________________________
A – STATE
B – MARTA
B-SPECIAL
C – LOCAL D- HOMESTEAD
E- EDUCATION F- MOTOR FUEL
TOTALS
1. Amount Claimed
2. Amount Rejected
3. Additional Tax, Penalty
and/or Interest Assessed
or to be refunded
4. Amount Allowed
5. Amount Interest
From_______________
MM/DD/YY
To_________________
MM/DD/YY
6. Total Cols. A,
, C,
D, E, F
B
7. Total Refund
8. Approved for Credit Memorandum [ ]
Cash Refund [ ]
Verified By_________________________________
EXAMINING AUDITOR
Approved By________________________________
TITLE
Examined and
Approved By________________________________
REFUND SECTION
Approved___________________________________
Date_______________________________________
DATE_______________ 20 _____.
Month/Day ex. 6/3
Based on the facts as stated in this claim for refund and on the certificate of the Examining and Approving Auditor, as above, it is
directed that a _________________________ be issued in the amount of $ _________________________.
__________________________________________________
DIRECTOR
(or authorized designee based upon claim amount)

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