Form St-12b - Purchaser'S Claim For Sales Tax Refund Affidavit

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ST-12B (Rev 1/12)

Georgia Department of Revenue

Taxpayer Services Division

1800 Century Blvd. NE

Atlanta, GA 30345-3205

1(877) 423-6711

PURCHASER’S CLAIM FOR SALES TAX REFUND AFFIDAVIT

PLEASE RETAIN A COPY FOR FUTURE AUDIT

Name of Purchaser

Purchaser’s Sales Tax Number (if Purchaser does not have a Sales Tax

Number, provide Federal Employer Identification Number or Social

Security Number)

Dealer’s Sales Tax Number (if known)

Name of Dealer

Dealer’s Street Address

City

State

Zip Code

Date of

Invoice No.

Gross Amount

Exempt Portion

Tax Paid by

Item Purchased

Purchase

of Sale

Purchaser to

Excluding Tax

Dealer

Did you request a sales tax refund from the Dealer?

Yes

No. If yes, on what date? ____________________. If no, why not?________

____________________________________________________________________________________________________________________

Enclose a copy of your request; and

Enclose a copy of proof of mailing or proof of delivery.

Did the Dealer refund any sales tax to you?

Yes

No. If yes, how much? $_______________________

Did the Dealer act upon your request for refund in any way?

Yes

No. If yes, what did the Dealer do? _________________________

Under penalties of perjury, I swear or affirm that I have personal knowledge and understanding of the statements made in this sales tax claim for

refund. The facts given in the claim and affidavit are true, correct and complete to the best of my knowledge and belief. I further understand that false

statements could result in criminal prosecution as well as the repayment of any refunded tax, plus interest and penalties.

__________________________________________

_____________________________________________________

Purchaser’s Signature

Purchaser’s Name and Title (if applicable)

Subscribed and sworn to me, this _______ day of ____________________, __________.

Notary Signature: ______________________________________________________

[Notary seal]

Typed or Printed Name of Notary: _________________________________________

NOTARY PUBLIC

THIS AFFIDAVIT SHALL BE ATTACHED TO FORM ST-12 AND MADE A PART OF PURCHASER’S SALES TAX CLAIM FOR REFUND