Fillable Form St-12a - Waiver Of Vendor'S Rights For Refund printable pdf download

Form St-12a - Waiver Of Vendor'S Rights For Refund

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ST-12A (Rev 04/07)

DEPARTMENT OF REVENUE

TAXPAYER SERVICES DIVISION

1800 Century Boulevard NE, Ste. 8214

Atlanta, Georgia 30345-3205

Telephone: (404) 417-6601

WAIVER OF VENDOR’S RIGHTS

FOR REFUND

Clear Form

Purchaser’s Certificate Number

Name of Purchaser

Name of Vendor

Vendor’s Certificate Number

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

Gross Amount

Exempt

Tax Paid

Date

Invoice No.

of Sale

Portion, if any,

To Vendor

Item Sold

MM/DD/YY

Excluding Tax

of Sale

By Purchaser

AFFIDAVIT OF VENDOR

The undersigned authorized representative of the above-named vendor 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 sales tax shown paid was collected from this purchaser and was remitted to the

Department of Revenue, and that this vendor disclaims any interest in said sales taxes remitted to the Department of Revenue and waives any right to refunds due

therefor.

This day of _________________,______.

______________________________________________

Vendor

By: ___________________________________________

Name and Title

Subscribed and sworn to:

This ____ day of ____________,______.

_____________________________________

Notary Public

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