Form St-12 - Claim For Refund - 2016
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ST-12
MAIL TO:
(Rev. 07/27/16)
Georgia Department of Revenue
1800 Century Boulevard NE, 8th Floor
Atlanta, Georgia 30345-3205
Telephone: 1-877-423-6711
CLAIM FOR REFUND
For more information on filing electronically visit Georgia Tax Center (GTC) at https://gtc.dor.ga.gov/_/.
Refund claims must be filed with the Department within three years from the date the tax was paid. O.C.G.A. § 48-2-35.
When the sales tax to be refunded was paid to a vendor, the Claim for Refund (Form ST-12) must be accompanied by a
properly completed Waiver of Vendor's Rights (Form ST-12A) or a Purchaser's Claim for Sales Tax Refund Affidavit
(Form ST-12B). When the claimant has remitted use tax directly to the Department, the ST-12A and ST-12B are not
required. Please include all supporting documents for the refund claimed, including invoices, proof of payment, sales
journals, etc. Refund claims received without supporting documentation may be delayed or denied.
__________________________________________________________________________________________________________________________________________________________________________________________________
Name of Taxpayer __________________________________________________________________________________
Address __________________________________________________________________________________________
City ______________________________________________________ State_______
Zip Code_________________
Contact Name __________________________________________________ Phone Number _______________________
Fax Number _______________________
Email Address __________________________________________________
Check the box to indicate who remitted the Sales and Use Tax: Claimant [ ]
Vendor [ ]
Tax Type: Sales [ ] Use [ ] 911 Prepaid Wireless [ ]
Fireworks Excise [ ]
State Hotel-Motel Fee [ ]
Tax ID Number___________________________
(For The Applicable Tax Type Selected)
Amount Paid $ __________________________ Amount Claimed as Refund $ ___________________________
Period (s) of Claim_______________________________
Claimant verily believes that this claim should be allowed for the following reasons: (State in detail the factual and legal
basis of claim. Attach additional pages if necessary.)
Under penalties of perjury, I swear that I have examined this claim and that the facts given in the claim and in
the supporting documents are true and correct.
_____________________________________________
_____________________________________________
SIGNATURE OF CLAIMANT OR CLAIMANT’S AUTHORIZED AGENT
DATE
_____________________________________________
TITLE
(If attorney in fact, attach Power of Attorney Form RD-1061)
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