Form C-245 Draft - Application For Appeal (Page 2 of 2) in pdf

Form C-245 Draft - Application For Appeal Page 2

DRAFT

8/1/07

Taxpayer's Signature

Date

Spouse's Signature

Date

Corporation's Name (if applicable)

Title

Signature of Owner/Partner/Officer/LLC Member

Date

Print Name

INSTRUCTIONS

The purpose of this form is to reduce to writing those facts and issues with which you disagree. If more space is needed,

additional sheets may accompany this form. A protest may be filed by letter rather than using this form; however, all of the

information required by this form must be included in the letter and you must comply with the requirements concerning

signatures. If you file a joint income tax return, both you and your spouse must sign. If the protest is for a corporation, it

must include the corporation's name followed by the signature and title of the corporate officer authorized to sign. If you

have any questions concerning this matter, please call the telephone number on the notice or document with which you

disagree. Please return document to the Department of Revenue address shown on the notice or document with which

you disagree.

Social Security Privacy Act Disclosure

It is mandatory that you provide your social security number on this tax form. 42 U.S.C 405(c)(2)(C)(i) permits a state to use an

individual's social security number as means of identification in administration of any tax. SC Regulation 117-201 mandates that any

person required to make a return to the SC Department of Revenue shall provide identifying numbers, as prescribed, for securing

proper identification. Your social security number is used for identification purposes.

61772028

Form C-245 Draft - Application For Appeal Page 2