Form L-2170 - Supplier 10 Day Notification

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STATE OF SOUTH CAROLINA
1350
1350
DEPARTMENT OF REVENUE
L-2170
(Rev. 9/18/08)
SUPPLIER 10 DAY NOTIFICATION
4320
ATTN: MOTOR FUEL SECTION
FAX NUMBER: (803) 896-1779
SUPPLIER INFORMATION
NAME:
FEI #:
SC LIC #:
This notification is for: (Check all that apply)
A.
Failure To Pay
B.
Rescinding E/P Status
C.
Late Payment
D.
Ten Day Notice Previous Submitted - Payment Received
Payment Received
Date Received
ELIGIBLE PURCHASER INFORMATION (Complete a notice for each purchaser.)
NAME:
FEI #:
PAYMENT DUE $
PAYMENT DUE DATE:
GALLONS NOT SUBJECT
USER FEE GALLONS
TOTAL GALLONS
TO USER FEE
GASOLINE
DIESEL
KEROSENE
OTHER
TOTAL GALLONS
PROPOSED CREDIT TO BE CLAIMED ON THE NEXT MONTH'S USER FEE REPORT $
ELIGIBLE PURCHASER STATUS:
The above listed purchaser has been notified of the termination of their eligible purchaser status.
(Check one)
Yes
No
If yes, provide date of notification.
COMMENT:
I hereby certify that the information provided above is true and correct to the best of my knowledge.
Signature
Date
Phone Number
Mail to: South Carolina Department of Revenue, Motor Fuel Reports, Columbia, SC 29214-0132.
43201011

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