Form L-2081 - Biennial Coin-Operated Device Application - 2004/2006
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1
2STATE OF SOUTH CAROLINA
L-2081
2004
2006
DEPARTMENT OF REVENUE
(Rev. 3/30/04)
BIENNIAL COIN-OPERATED DEVICE
4163
APPLICATION
Mail to: SCDOR, COD Section, Columbia, SC 29214-0135
Telephone: (803) 898-5000 DOR Website:
File #:
For Office Use Only
IMPORTANT INFORMATION: Biennial Licenses are prorated to correspond to the month
licenses are purchased (see chart below). They are non-refundable and non-transferable.
Type I
License No
You may apply for these licenses in person at the SC Department of Revenue, 301
Gervais St., Columbia, or at our Taxpayer Service Centers located in Charleston - 3
DLN
Southpark Circle, Suite 202; Florence - 1452 West Evans St; Greenville - 211 Century
Drive, Suite 210B; Myrtle Beach - 1330 Howard Parkway; Rock Hill - Business and
Technology Center, 454 S Anderson Rd, Suite 202.
Amount
$
PLEASE TYPE OR PRINT:
14-1501-0010
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
$
14-1501-0010
No. Type I Machines
License Tax
Total
Beg:
$
$
X
=
No. Type II Machines
License Tax
Total
End:
$
$
X
=
Type IV
SLED
No. Type III Machines
License Tax
Total
DLN
$
$
X
=
Total Remitted for all
$
Licenses (Types)
Amount
$
34-3973-9400
All licenses are non-transferable and valid through May 31, 2006.
Month of
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
purchase
License
$50
$48
$46
$44
$42
$40
$38
$35
$33
$31
$29
$27
TYPE I
Tax
License
$250
$242
$233
$225
$217
$208
$200
$192
$183
$175
$167
$158
TYPE II
Tax
License
$4000
$3833 $3667 $3500 $3333 $3167 $3000 $2833 $2667 $2500 $2333 $2167
TYPE III
Tax
Remit license tax that corresponds with the month the application is submitted. See reverse for license types
I hereby certify that the owner/operator, whether individual, partnership, LLC, or corporation, shall own or
operate 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
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