Form St-12 - Georgia Tourism Development Act Claim For Refund

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ST-12 TOURISM (12/11)
GEORGIA TOURISM DEVELOPMENT ACT
CLAIM FOR REFUND
STATE OF GEORGIA
DEPARTMENT OF REVENUE
COMPLIANCE SERVICES DIVISION
1800 Century Boul evard NE, Ste. 18100
Atlanta, Georgia 30345-3205
Telephone: (404) 417-6400
Fax: (404) 417-6551
__________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Name of Approved Company _ Title___________________________________
Business Address _____________________________________________________________________________________________
City or Town _________________________ County _________________________ State _______________ Zip Code ___________
Permanent Address ___________________________________________________________________________________________
City or Town _________________________ County _________________________ State _______________ Zip Code ___________
Email Address _________________________________________________________Fax___________________________________
Sales Tax Certificate No. _________________________ FEIN _____ Soc. Sec. No. ______________
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.)
Attach a copy of the Tourism Development agreement with the Department of Community Affairs.
________________________________________________________________________________________________________________________________________________________________________________________________________________________
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.
Signed this _____ day of _______________, 20 _____
__________________________________________________
SIGNATURE OF CLAIMANT OR CLAIMANT’S AUTHORIZED AGENT
__________________________________________________
Title
(If attorney in fact, attach power of attorney Form RD-1061)

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