Form - Refund Request (Rev. 1 0 /2018 ) Secretary of State OFFICE OF SECRETARY OF STATE CORPOR A TIONS DIVISION 2 Martin Luther King Jr. Dr. SE Suite 313 West Tower Atlanta, Georgia 30334 (404) 656 - 2817 sos.georgia.gov/corporations 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 r efunded: Reason(s) for refund request: Cardholder Name: Last Four Digits of Credit/Debit Card Used: Expiration Date of Credit/Debit Card Used : Contact Information: Name: Phone: Address: City: State: Zip Code: Email address: 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. American LegalNet, Inc. www.FormsWorkFlow.com