Form Abl 571c - Abl 571 Checklist Page 2
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7STATE OF SOUTH CAROLINA
1350
1350
DEPARTMENT OF REVENUE
ABL-571
APPLICATION FOR OUT OF STATE
(Rev. 10/28/14)
4310
WINE SHIPPERS LICENSE
Physical Address: SC Department of Revenue, ABL Section, 300A Outlet Pointe
File Number:
Blvd, Columbia, SC 29210
Mail to: SC Department of Revenue, ABL Section, Columbia, SC 29214-0907
Telephone: (803) 898-5864
DOR Website:
PLEASE PRINT OR TYPE ALL INFORMATION
Fee: $600 Biennially
(Expires August 31st of even numbered years)
PLEASE PRINT OR TYPE ALL INFORMATION
1. OWNER, PARTNERSHIP, OR CORPORATE CHARTER NAME
6. TRADE NAME (DOING BUSINESS AS)
2. PHYSICAL LOCATION OF BUSINESS REQUIRED (NO P.O. BOX)
STREET
7. BUSINESS PHONE NUMBER
DAYTIME PHONE NUMBER
CITY
COUNTY (REQUIRED)
STATE
ZIP
3. MAILING ADDRESS (FOR ALL CORRESPONDENCE)
8. FEDERAL IDENTIFICATION NUMBER AND/OR SOCIAL SECURITY NO.
“In compliance with the Federal Privacy Act of 1974, the disclosure of an
individual’s social security number on this form is mandatory*. SC regulation
IN CARE OF
117-201 provides that any person required to make a return, statement or
document to the Department must include identifying numbers on such return,
statement or document if the Department requests such information. Social
STREET
security numbers are primarily used for the purposes of identifying taxpayers
and monitoring tax compliance and/or fraud.”
CITY
COUNTY
STATE
ZIP
4. TYPE OF OWNERSHIP
9. LOCATION OF RECORD (NO P.O. BOX)
SOLE PROPRIETOR (one owner)
PARTNERSHIP (two or more owners)
LLC/LLP
SC CORPORATION DATE INC.
FOREIGN CORPORATION
STATE INC.
DATE OF INC.
NON-PROFIT ORGANIZATION
10. RETAIL SALES TAX LICENSE #
OTHER (EXPLAIN)
5. EMAIL ADDRESS
11.
If the corporation is publicly traded, you must designate an officer or
other person to hold the license. This person must be of good moral
character, over the age 21, and a SC resident. This person should be
included on the Consent and Waiver along with other principals of the
corporation.
Name of designated officer or other employee:
43101021
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