SOUTH CAROLINA DEPARTMENT OF REVENUE
Alcoholic Beverage Licensing
301 Gervais St. - Columbia, SC 29214
Administrator, Executor or Executrix of an Estate
File with this form: a copy of the death certificate and a copy of your appointment by the probate court.
This form is to be completed by the Administrator, Executor or Executrix of the estate of a deceased permittee
and/or licensee.
The below is to be completed by the Administrator, Executor or Executrix:
Name____________________________________________
Date of Birth__________________________
Social Security Number_____________________________
Telephone Number_____________________
Home Address_______________________________________________________________________________
City________________________________ County____________________________ Zip Code___________
Licensee and/or permittee information:
Name of deceased licensee and/or permittee (please list name as it appears on current license/permit)___________
_____________________________________________________________________________________________
Name of business (as it appears on current license/permit______________________________________________
Business address (as it appears on current license/permit______________________________________________
City_____________________________
County_________________________
Zip Code____________
Current license and/or permit number (s)______________________________________
If more than one license and/or permit is affected, please indicate below and file additional copies of this form for
each license/permit. You may make copies of this form to submit for other licenses/permits held.
Additional licenses/permits
(
)Yes
(
)No
Sworn to and subscribed before me this
______day of_____________19____
_______________________________
________________________________________
Notary Public for South Carolina
Administrator, Executor or Executrix
ABL 501 (Rev. 5/95)