STATE OF SOUTH CAROLINA
1350
1350
DEPARTMENT OF REVENUE
L-2098
(Rev. 10/5/12)
MOTOR FUEL TERMINAL OPERATOR
4186
MONTHLY RETURN
Mail to: South Carolina Department of Revenue, Motor Fuel, Columbia, SC 29214-0132.
The Return is Due on the 22nd of the Next Month.
Office Use Only
OPERATOR NAME AND ADDRESS
34-2101
License Number
FEIN
NAME AND PHYSICAL ADDRESS OF TERMINAL
Terminal Code
Month/Year
COMPLETE MONTHLY SUMMARY OF TRANSACTIONS FOR THE MONTH
(LOCATED ON THE BACK OF THIS REPORT)
S.C. Code of Laws 1976 As Amended: Code Section 12-54-210 (a) states: A person liable for a tax, license, fee, or
surcharge administered by the department or for the filing of a return with the department, including information
returns shall keep books, papers, memoranda, records, render statements, make returns, and comply with
regulations as the department prescribes. Persons failing to comply with the provisions of this section must be penalized
in an amount to be assessed by the department not to exceed five hundred dollars for the period covered by the
return in addition to other penalties provided by law
I hereby certify that the information contained in this return (including accompanying schedules and statements) has been
examined by me and to the best of my knowledge is true, correct and a complete return.
Name:
Signature:
(Print)
Phone Number:
Date:
41861014