Form I-309 - Nonresident Shareholder Or Partner Affidavit And Agreement Income Tax Withholding

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STATE OF SOUTH CAROLINA
1350
1350
DEPARTMENT OF REVENUE
I-309
NONRESIDENT SHAREHOLDER OR PARTNER AFFIDAVIT
(Rev. 10/5/07)
AND AGREEMENT INCOME TAX WITHHOLDING
3313
The undersigned taxpayer on oath, being first duly sworn, hereby certifies and agrees as follows:
1.
I am a nonresident shareholder or partner.
My name is:
2.
My address is:
(number and street)
(city, state, and zip code)
3.
My social security number or Federal Employer Identification Number (FEI) is:
4.
The type of income for which this affidavit and agreement applies is:
Distributed or undistributed South Carolina income from an S-corporation.
Distributed or undistributed South Carolina income from a partnership.
The entity's name is:
The entity's address is:
(number and street)
(city, state, and zip code)
The entity's Federal Employer Identification Number (FEI) is:
5.
I agree to timely file appropriate returns and make payment of all South Carolina taxes required by law.
6.
I agree that I am subject to the personal jurisdiction of the South Carolina Department of Revenue and the courts of
South Carolina for the purpose of determining and collecting any South Carolina taxes, including estimated taxes,
together with any related interest and penalties.
7.
This agreement will be binding upon my heirs, representatives, assigns, successors, executors and administrators.
8.
I understand the South Carolina Department of Revenue may revoke the withholding exemption granted under Code
Section 12-8-590(F) at any time it determines I am not abiding by the terms of this agreement.
The undersigned understands that any false statement contained herein could be punished by fine, imprisonment, or both.
Recognizing that I am subject to the criminal penalties under Code Section 12-54-44(B) (6) (a) (i), I declare that I have
examined this affidavit and agreement and, to the best of my knowledge and belief, it is true, correct and complete.
(Seal)
(Signature of shareholder or partner)
(Date)
(Name - Please print)
33131020

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