Form Mf-12 - Waiver Of Seller'S Rights For Refund

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Mailing Address

MF-12

Form

(Rev. 2/13)

Georgia Department of Revenue

Taxpayer Services Division

1800 Century Center Blvd., NE, Ste. 8223

Atlanta, Georgia 30345-3205

Telephone (404) 417-6710

WAIVER OF SELLER’S RIGHTS FOR REFUND

Name of Seller

Seller’s License Number

f o

r u

h c

s a

r e

Address

City or Town

State

ZIP Code

Tax Paid to

Exempt Portion

Type of Fuel

Date

Invoice No.

Gallons

Seller by

( If applicable)

Purchaser

AFFIDAVIT OF SELLER

The undersigned authorized representative of the above-named seller 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 motor fuel tax shown paid was collected from the above named purchaser and was

remitted to the Department of Revenue, and that this seller disclaims any interest in said motor fuel taxes remitted to the Department of Revenue and waives any

right to refunds due therefor.

This day of _________________,______.

______________________________________________

Seller

___________________

Subscribed and sworn to:

Telephone Number

This ____ day of ____________,______.

By: ___________________________________________

Name and Title

_____________________________________

Notary Public