Form L-2157 - Eight Month Coin-Operated Device Application - 2011
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1
2STATE OF SOUTH CAROLINA
1350
1350
DEPARTMENT OF REVENUE
L-2157
EIGHT MONTH COIN-OPERATED
(Rev. 3/31/11)
4299
DEVICE APPLICATION
Mail to: SCDOR, COD Section, Columbia, SC 29214-0135
File #:
Telephone: (803) 898-5601 DOR Website:
IMPORTANT INFORMATION: Eight Month Licenses are not prorated. They are
For Office Use Only
non-refundable and non-transferable. You may apply for these licenses in person at
Type I
License No
the SC Department of Revenue, 301 Gervais St., Columbia, or at our Taxpayer
Service Centers located in Charleston - 1 South Park Circle, Suite 100; Florence -
DLN
1452 West Evans St; Greenville - 545 North Pleasantburg Dr., Suite 300; Myrtle
Beach - 1330 Howard Parkway; Rock Hill - Business and Technology Center, 454 S
Anderson Rd., Suite 202.
Amount
$
PLEASE TYPE OR PRINT:
14-1501
1.
Name
Title
Beg:
2.
Business Name
End:
3.
Business Address
Type II
License No
City
State
Zip Code
DLN
4.
Federal ID Number
Telephone Number
Amount
$
14-1501
No. Type I Machines
License Tax
Total
17.00
Beg:
X $
$
=
No. Type II Machines
License Tax
Total
End:
84.00
X $
$
=
Type IV
SLED
No. Type III Machines
License Tax
Total
DLN
1333.00
X $
$
=
Total Remitted for all
$
Licenses (Types)
Amount
$
34-3973-9400
All licenses are non-transferable and valid from March 1 through the following October 31.
See reverse for license types.
I hereby certify that the owner/operator, whether individual, partnership, LLC, or corporation, shall own or operate
Dist. Code
only legal machines in this state, and that the information given in this application is true and correct to the best of
my knowledge and belief.
Signature of Owner/All Partners/ Officer
Date
42991026
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