Form St-397 - Solvent Surcharge Return
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1
2STATE OF SOUTH CAROLINA
1350
1350
DEPARTMENT OF REVENUE
ST-397
SOLVENT SURCHARGE RETURN
(Rev. 9/2/09)
Mail To: SC Department of Revenue Solvent Surcharge Return
5076
Columbia, SC 29214-0103
EFT
Name and Address
Registration Number
FEI Number
Period Covered
CALCULATIONS OF SOLVENT SURCHARGE
1.
Gallons of Halogenated Drycleaning Fluid Sold
1.
2.
Line 1x $10.00/gallon
2.
3.
Penalty
3.
4.
Interest
4.
FOR OFFICE USE ONLY
5.
Total Surcharge on Fluid (Add lines 2, 3, and 4)
5.
34-3516
6.
Gallons of Nonhalogenated Cleaner Sold
6.
7.
Line 6 x $2.00/gallon
7.
8.
Penalty
8.
9.
Interest
9.
FOR OFFICE USE ONLY
10.
Total Surcharge on Cleaner
10.
(Add lines 7, 8, and 9)
34-3518
11.
Total Due (Add lines 5 and 10 )
11.
I hereby certify that the information contained in this report (including all accompanying schedules and statements) has
been examined by me and to the best of my knowledge is correct and complete.
Signature
Title
Date
Daytime Phone Number
Due Date: Form ST-397 is due on or before the 20th day of the month following the period covered and becomes
delinquent on the 21st day.
50761014
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