SOUTH CAROLINA SECRETARY OF STATE MUNICIPALITIES DIVISION SPECIAL PURPOSE DISTRICT NOTIFICATION FORM Filing Instructions Every Special Purpose District must submit this form to the Secretary of State by December 31st of every even numbered year. Failure to file this form could lead to a declaration that the special purpose district is inactive and a suspension of county funding to the district. Please contact our office with any questions regarding this form at 803-734-1790 or email spd@sos.sc.gov. We do not accept this filing by fax or email; you may deliver by hand or mail to South Carolina Secretary of State, Attn: Municipalities, 1205 Pendleton St., Suite 525, Columbia, SC 29201. Please type or print clearly. ____________________________________________________________________ Legal Name of Special Purpose District __________ SPD# 1. Physical address: _________________________________________________________________ Street Address, City, State, Zip Code 2. If you do not have a physical address, please provide the name, address and telephone number of your registered agent: _________________________________________ Registered Agent Name __________________________________________________________________________________________ Street Address, City, State, Zip Code 3. Person completing this form: __________________________ ________________ Name Address, City, State, Zip Code 4. Describe services provided: ________________________________________________________________________________ 5. Tax rate or fee charged (attach a separate sheet if necessary): _________________________________________________________________________________ 6. Date the Act or Ordinance passed that created your special purpose district: ____________________ Phone _____________________________ Email __________________________________________________________________________________________ Special Purpose District Notification Form, revised August 2012 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 7. Citation of statutory authority: ______________________________________________________ If this is your first registration with the Secretary of State's Office, you are required to provide a copy of the Act or Ordinance that created your special purpose district. If there have been any amendments to the Act or Ordinance that created your special purpose district since your last registration with the Secretary of State's Office, please include a copy. 8. General description of geographical boundary of service area: _________________________________________________________________________________ _________________________________________________________________________________ If this is your first registration with the Secretary of State's Office, you are required to provide a copy of the legal description of your geographical service area boundaries. If there have been any amendments to the boundaries of the service area since your last registration with the Secretary of State's Office, please include a copy. 9. Counties in which the district is located: ________________________________________________ 10. Method of selecting members of governing body: ________________________________________ 11. Names of members of governing body and terms of office (attach a separate sheet if necessary): Name Title Term Ends ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ __________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________ Financial Summary Financial Information for Fiscal Year ______________ to ______________ (mo/day/year) (mo/day/year) Total Revenue: _____________________ Total Expenses: __________________________ Special Purpose District Notification Form, revised August 2012 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Total Debt: __________________ (Provide an itemization of debts below; attach a separate sheet if necessary). Debts __________________________________________ __________________________________________ __________________________________________ __________________________________________ Total Investments: ____________________ (Itemize investments below; attach a separate sheet if necessary). Institution Where Held __________________________________________ __________________________________________ __________________________________________ __________________________________________ Interest Rate __________ __________ __________ __________ Amount _______________________ _______________________ _______________________ _______________________ Bonded (Yes or No) Amount _______________________ _______________________ _______________________ _______________________ __________ __________ __________ __________ Auditor(s) Signature Per S. C. Code Section 6-11-1620(C), the auditor of the county in which the special purpose district is located must inspect and sign the notification form. If the district listed two counties in Item 9 above, the auditor of the second county must also sign below. Signature of County Auditor: Auditor's Name: _______________________________________________ Signature of Auditor: ____________________________________________ Name of County: _______________________________________________ Date: _______________________ Signature of County Auditor of Second County (if applicable): Auditor's Name: _______________________________________________ Signature of Auditor: ____________________________________________ Name of County: _______________________________________________ Date: _______________________ Special Purpose District Notification Form, revised August 2012 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com