1350 STATE OF SOUTH CAROLINA ABL-62 DEPARTMENT OF REVENUE AFFIDAVIT FOR NONPROFIT PRIVATE CLUB RENEWAL (Rev. 5/4/11) 4255 MAIL TO: South Carolina Department of Revenue, ABL Section, 301 Gervais Street, PO Box 125, Columbia, SC 29214-0907. Alcohol Beverage Licensing File#: ORGANIZATION/PRIVATE CLUB NAME ORGANIZATION/PRIVATE CLUB ADDRESS CITY COUNTY ZIP Personally appeared before me , who being duly sworn states that he/she is an authorized officer for the above named organization/private club and that such organization/private club is being operated on a nonprofit and limited membership basis. Sworn to and subscribed before me this day of year of Notary Public for South Carolina Signature and Title of Authorized Officer My Commission Expires NOTE: In accordance with Department of Revenue Regulation 7-401.4, please be advised that it will be necessary for you to file the following information with your renewal: 1. A Financial Statement showing a schedule of the organization’s assets and liabilities, and a Profit and Loss Statement (you may use the profit and loss statement attached or a copy of the one submitted to the IRS), signed by an authorized officer of the organization/private club for the latest calendar year or fiscal year. If the private club has been operating for less than one (1) year the Financial Statement and Profit and Loss Statement are not required. THE ORGANIZATION’S LICENSE WILL NOT BE RENEWED WITHOUT THIS FORM AND ATTACHMENTS. 2. Any change in the following during the preceding twelve (12) months: (please indicate and specify below). Organization/Private Club Constitution: Bylaws: Articles of Incorporation: Officers/Directors: Please specify changes: 42551028 American LegalNet, Inc. www.FormsWorkFlow.com Profit and Loss Statement ABL File #: Name of business: Fiscal Year or Calendar Year: Income Memberships Dues Liquor by the Drink (LBD) Sales Sales – Other Other (Specify) Total Income Operating expenses Accounting Advertising Auto expenses Contributions Depreciation Entertainment Insurance Interest Legal Licenses Miscellaneous Office expense Other (specify) Postage/printing Rent Repairs/Maintenance Salaries Supplies Taxes - LBD Taxes - Payroll Taxes - Sales Telephone Trade Dues Utility Wages Other (specify) TOTAL EXPENSES Profit/(Loss) 42552026 American LegalNet, Inc. www.FormsWorkFlow.com