1350 STATE OF SOUTH CAROLINA DEPARTMENT OF REVENUE ABL-501 (Rev. 7/31/08) 4271 NOTIFICATION OF DECEASED LICENSEE MAIL TO: SC Department of Revenue, ABL Section, Columbia, SC 29214-0907. Telephone: (803) 898-5864 File with this form: a copy of the death certificate and a copy of your appointment by the probate court. The below is to be completed by the Administrator, Executor, Executrix, or Personal Representative: Name Social Security Number Home Address City Licensee and/or permittee information: County Zip Code Date of Birth Telephone Number Name of deceased licensee and/or permittee (please list name as it appears on current license/permit) Name of business (as it appears on current license/permit) Business address (as it appears on current license/permit) City Current license and/or permit number(s) If more than one license and/or permit is affected, please indicate below and file additional copies of this form for each license/permit. You may make copies of this form to submit for other licenses/permits held. Additional licenses/permits Yes No County Zip Code Sworn to and subscribed before me this day of year of Notary Public for South Carolina Signature of Administrator, Executor, Executrix, or Personal Representative My Commission Expires NOTE: This license change is valid until deceased's estate is probated. Individual must file new application at that time. 42711010 American LegalNet, Inc. www.FormsWorkFlow.com