"Refund Request Form" - Georgia (United States)

Refund Request Form is a legal document that was released by the Georgia Secretary of State - a government authority operating within Georgia (United States).

Form Details:

  • Released on October 1, 2018;
  • The latest edition currently provided by the Georgia Secretary of State;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Georgia Secretary of State.

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OFFICE OF SECRETARY OF STATE
CORPORATIONS DIVISION
2 Martin Luther King Jr. Dr. SE
Suite 313 West Tower
Atlanta, Georgia 30334
(404) 656-2817
sos.georgia.gov/corporations
Secretary of State
REFUND REQUEST
Date of Request: _____________________
Date of Transaction: _____________________
Control Number: _____________________
Entity Name: __________________________________________________________________
Original Amount Paid: ________________
Invoice Number: ________________________
Payment Method:
_____ Check
_____ Credit Card
Amount to be refunded: ____________________
Reason(s) for refund request: ______________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Cardholder Name: ______________________________________________________________
Last Four Digits of Credit/Debit Card Used: _____________________
Expiration Date of Credit/Debit Card Used: _____________________
Requestor’s Contact Information:
Name: _____________________________________
Phone: _____________________________________
Address: ______________________________________________________________________
City: _________________________
State: _____________
Zip Code: ______________
Email address: _________________________________________________________________
Requestor’s Signature: ___________________________________________________________
Refund requests are valid only if submitted within 6 months of the original
date of payment and all supporting documentation is attached to this form.
Please complete and return this form with any supporting documents to the Corporations
Division by emailing to refundrequestform@sos.ga.gov. Should you choose to mail your request,
please send it to the address listed above. Please submit only one request per form.
Form - Refund Request
(Rev. 10/2018)
OFFICE OF SECRETARY OF STATE
CORPORATIONS DIVISION
2 Martin Luther King Jr. Dr. SE
Suite 313 West Tower
Atlanta, Georgia 30334
(404) 656-2817
sos.georgia.gov/corporations
Secretary of State
REFUND REQUEST
Date of Request: _____________________
Date of Transaction: _____________________
Control Number: _____________________
Entity Name: __________________________________________________________________
Original Amount Paid: ________________
Invoice Number: ________________________
Payment Method:
_____ Check
_____ Credit Card
Amount to be refunded: ____________________
Reason(s) for refund request: ______________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Cardholder Name: ______________________________________________________________
Last Four Digits of Credit/Debit Card Used: _____________________
Expiration Date of Credit/Debit Card Used: _____________________
Requestor’s Contact Information:
Name: _____________________________________
Phone: _____________________________________
Address: ______________________________________________________________________
City: _________________________
State: _____________
Zip Code: ______________
Email address: _________________________________________________________________
Requestor’s Signature: ___________________________________________________________
Refund requests are valid only if submitted within 6 months of the original
date of payment and all supporting documentation is attached to this form.
Please complete and return this form with any supporting documents to the Corporations
Division by emailing to refundrequestform@sos.ga.gov. Should you choose to mail your request,
please send it to the address listed above. Please submit only one request per form.
Form - Refund Request
(Rev. 10/2018)