Form Abl-62 - Affidavit For Nonprofit Private Club Renewal - 2011

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1350
1350
STATE OF SOUTH CAROLINA
STATE OF SOUTH CAROLINA
ABL-62
DEPARTMENT OF REVENUE
DEPARTMENT OF REVENUE
(Rev. 5/4/11)
AFFIDAVIT FOR NONPROFIT PRIVATE CLUB RENEWAL
4255
MAIL TO: South Carolina Department of Revenue, ABL Section, 301 Gervais Street, PO Box 125, Columbia, SC 29214-0907.
Alcohol Beverage Licensing File#:
ORGANIZATION/PRIVATE CLUB NAME
ORGANIZATION/PRIVATE CLUB ADDRESS
CITY
COUNTY
ZIP
Personally appeared before me
, who being duly sworn states
that he/she is an authorized officer for the above named organization/private club and that such organization/private
club is being operated on a nonprofit and limited membership basis.
Sworn to and subscribed before me
this
day of
year of
Notary Public for South Carolina
Signature and Title of Authorized Officer
My Commission Expires
NOTE:
In accordance with Department of Revenue Regulation 7-401.4, please be advised that it will be necessary
for you to file the following information with your renewal:
1.
A Financial Statement showing a schedule of the organization’s assets and liabilities, and a Profit and Loss
Statement (you may use the profit and loss statement attached or a copy of the one submitted to the IRS),
signed by an authorized officer of the organization/private club for the latest calendar year or fiscal year. If the
private club has been operating for less than one (1) year the Financial Statement and Profit and Loss
Statement are not required.
THE ORGANIZATION’S LICENSE WILL NOT BE RENEWED WITHOUT THIS FORM AND ATTACHMENTS.
2.
Any change in the following during the preceding twelve (12) months: (please indicate and specify below).
Organization/Private Club Constitution:
Bylaws:
Articles of Incorporation:
Officers/Directors:
Please specify changes:
42551028

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