Form Fs-102 - Payment Plan Request
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1350
STATE OF SOUTH CAROLINA
FS-102
DEPARTMENT OF REVENUE
(Rev. 1/24/17)
PAYMENT PLAN REQUEST
2094
Date
To request a payment plan apply online at dor.sc.gov/payplan or complete the applicable sections below.
A nonrefundable payment plan fee of $45 will be applied to your balance.
SSN/FEIN
Name and Address
Email Address
Phone Number
Balance Due
Monthly Payment Amount
Banking Institution
Draft Date (1st-28th)
Routing Transit Number
Office Use Only
Account Number
Penalty and interest will continue to accrue until the liability is paid in full. This may increase your total monthly installments from your
original submission. I agree for SCDOR to continue to electronically withdraw funds per the above agreement on a monthly basis until
my liability is satisfied. I agree for SCDOR to immediately withdraw my first monthly payment upon receipt of this request.
I hereby waive all rights under Chapter 60 of Title 12 of the SC Code of Laws including but not limited to 12-60-420, 12-60-440 and
12-60-450. These rights include but are not limited to any appeal rights, notice requirements, and/or the 90 day period to appeal a
notice of proposed assessment. I agree to an immediate assessment prior to the end of the 90 day appeal period. I understand the
above includes any amount for which a return is due or past due, any notice of proposed assessment, any assessment, and any lien.
I fully understand that liens may be filed and recorded for all amounts owed, lien cost will be added to the balance and liens
will negatively affect my credit rating or the credit rating of my company.
Submission of my account information is authorization for:
1. The South Carolina Department of Revenue and its designated financial agents to initiate an Electronic Funds Withdrawal
(payment) entry to my financial institution account designated for payment of my South Carolina taxes owed, and
2. My financial institution(s) to debit the entry from my account. I also authorize the financial institution(s) involved in the
processing of my electronic payment of taxes to receive confidential information necessary to answer inquiries and
resolve issues related to my payment.
3. Funds for the payments will not come from an account outside the U.S.
Under the items of this authorization, I can revoke this authorization by notifying the South Carolina Department of Revenue no later
than five (5) business days prior to the withdrawal (settlement) date. I understand that notification must be made in writing and can be
emailed to PPARequest@dor.sc.gov.
Your Signature
Spouse's Signature
Date
(Required for EFW)
(If applicable)
Installment Terms
Tax Type
Balance Owed
Payment Terms
Individual
0-$999
12 Months or Less
Individual
$1,000-$4,999
24 Months or Less
Individual
$5,000-$9,999
36 Months or Less
Individual
$10,000 and above
48 Months or Less
Business
All Balances
Contact your Local Field Office
If you have any questions about payment plans, call 803-898-2222. Email this application to PPARequest@dor.sc.gov
or mail to SCDOR, Payment Plan, Columbia, SC 29214-0217.
20941027
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