Form Abl-956 - Affidavit Waiving Distance Requirement printable pdf download

Form Abl-956 - Affidavit Waiving Distance Requirement

1350

STATE OF SOUTH CAROLINA

ABL-956

DEPARTMENT OF REVENUE

(Rev. 7/25/14)

AFFIDAVIT WAIVING DISTANCE REQUIREMENT

4569

MAIL TO: South Carolina Department of Revenue, ABL Section, 300A Outlet Pointe Blvd., PO Box 125, Columbia, SC 29214-0907.

Alcohol Beverage Licensing File#:

ENTITY NAME

D/B/A NAME

PROPOSED LOCATION ADDRESS

CITY

COUNTY

ZIP

CHURCH/PLAYGROUND NAME

AUTHORIZED OFFICER/OFFICIAL

ADDRESS OF CHURCH/PLAYGROUND

CITY

COUNTY

ZIP

Personally appeared before me

, who being duly sworn

states that he/she is an authorized officer/official for the above named church/playground and that such

church/playground does NOT have any objections to the issuance of a Liquor by the Drink License at the

above named location (61-6-120). It is also understood that by signature of this affidavit that this waiver

would apply to any future applications for this location.

Sworn to and subscribed before me this

day of

, year of

Notary Public for

My commission expires

Notary (L.S.)

Notary (printed name)

Signature and Title of Authorized Officer/Official

45691011

Form Abl-956 - Affidavit Waiving Distance Requirement