Form Abl 3 - Internal Revenue Service Consent printable pdf download

Form Abl 3 - Internal Revenue Service Consent

South Carolina Department of Revenue

301 Gervais St., PO Box 125

Columbia, SC 29214

NOTE:

THIS FORM MUST BE COMPLETED, SIGNED BY THE APPLICANT AND

SUBMITTED TO THE SOUTH CAROLINA DEPARTMENT OF REVENUE WITH YOUR

APPLICATION. IF THIS CONSENT IS NOT FILED WITH YOUR APPLICATION, YOUR

LICENSE WILL NOT BE ISSUED.

INTERNAL REVENUE SERVICE CONSENT

Name of Applicant:______________________________________________________________________________

(Last)

(First)

(MI)

Home Address:__________________________________________________________________________________

______________________________________________________________________________________________

(City)

(State)

(Zip Code)

Applicant's social security number:________________________________________________________________

Exact address of proposed location (Do not list a PO Box)____________________________________________

County:_____________________________

This consent is given solely to meet the certification requirements in Section 61-3-425 of the Code of Laws of South Carolina

relating to the issuance or renewal of an alcoholic beverage license. I hereby give the South Carolina Department of Revenue

my consent to inquire of and receive from the Internal Revenue Service the status of my Federal income tax return filing and

payment history for the most current six years as of this date, plus the next five tax years.

This consent may be withdrawn by the applicant at any time by writing to the Internal Revenue Service Disclosure Officer, 1835 Assembly

Street, MDP15, Columbia, SC 29201.

Signed:_____________________________________________

Applicant's signature

Date:_______________________________________________

DO NOT WRITE IN THIS SPACE

AI #(s)_____________________

Date DOR forwarded to IRS______________________________________

ABL 3 Rev 10/96

Form Abl 3 - Internal Revenue Service Consent