1350 STATE OF SOUTH CAROLINA DEPARTMENT OF REVENUE APPLICATION FOR REGISTRATION OF BEER AND WINE PRODUCER OR IMPORTER Mail to: SC Department of Revenue, ABL Section, Columbia, SC 29214-0907 Telephone: (803) 898-5864 DOR Website: www.sctax.org ABL-500 (Rev. 9/30/10) 4270 File Number: PLEASE PRINT OR TYPE ALL INFORMATION Fee: $400 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 CITY COUNTY (REQUIRED) STATE DAYTIME PHONE NUMBER 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 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 security numbers are primarily used for the purposes of identifying taxpayers and monitoring tax compliance and/or fraud.” IN CARE OF STREET CITY COUNTY STATE ZIP 4. TYPE OF OWNERSHIP SOLE PROPRIETOR (one owner) PARTNERSHIP (two or more owners) LLC/LLP SC CORPORATION DATE INC. FOREIGN CORPORATION STATE INC. 9. DATE OF INC. NON-PROFIT ORGANIZATION CHECK ONE: BREWERY WINERY OTHER (EXPLAIN) IMPORTER: BEER WINE 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. TTB IMPORTER PERMIT # Name of designated officer or other employee: 5. DOES THE APPLICANT OWN OR HAVE FINANCIAL INTEREST IN A BEER OR WINE WHOLESALE OR RETAIL BUSINESS? IF SO, PLEASE SPECIFY. 42701011 American LegalNet, Inc. www.FormsWorkFlow.com I, (Name of individual or entity applying) Title hereby certify that the information contained in this application and the attached ABL-107A and ABL-107B is true and correct to the best of my knowledge and belief. The Department of Revenue shall have the right within the Statutory limitations to audit and examine the books and records, papers and memoranda of this form with respect to the administration and enforcement of laws administered by the SC Department of Revenue and the South Carolina Law Enforcement Division. DESIGNATED AGENT You must designate a person to receive all notices from the Department of Revenue concerning your permit/license. These notices will be sent to the person at the mailing address shown in question 3. It is your responsibility to keep the department advised of any change regarding this person or your mailing address as the law will presume you received all notices sent to the address you have given us. Name of Designated Agent: Signature of individual on behalf of applicant 42702019 American LegalNet, Inc. www.FormsWorkFlow.com CONSENT AND WAIVER ABL-946 Rev. 11/19/09 File Number: Name of Corporation, Partnership, LLC, etc. FEI S.C. Code Ann. Section 61-2-160 prohibits the issuance of any permit or license under Title 61 unless the Department determines that the applicant does not owe the State any delinquent taxes, penalties or interest. The signature(s) below authorizes the S.C. Department of Revenue, pursuant to the provisions of S.C. Code Ann. Section 12-54-240 and 30-2-10, et seq., to release to any party, person or entity, law enforcement request(s) for purposes of processing this application or responding to questions related thereto, including but not limited to an information related to problems with the application, reasons for denial, delinquent taxes, outstanding liabilities, failure to file returns, penalties and interest. The signature below also authorizes S.C. Law Enforcement Division (SLED) to check, examine and release to the Department of Revenue the criminal history record of the person(s) having signed below. If an application is made for a license or permit by a person other than an individual, all principals are deemed to be the applicant. S.C. Code Ann. Section 61-2-100(C). All principals of the applicant are therefore required to be disclosed to the Department of Revenue. SOCIAL SECURITY DISCLOSURE “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 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 security numbers are primarily used for the purposes of identifying taxpayers and monitoring tax compliance and/or fraud.” 1 - 12 is a list of principal types. Each principal type must complete and sign a box below. If a required principal does not sign, this application will be denied. Principal Types: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. The owner (if sole proprietorship); All officers of the business or entity which owns the business; All partners (limited partners that cannot exercise management control need not sign); All persons who own twenty-five percent (25%) or more of the value of the business entity; All persons who own twenty-five percent (25%) or more of the combined voting power of the business or entity; Members and Managers of a limited liability company which is managed by managers; Members of a limited liability company which is not managed by managers; Any fiduciary who manages, controls title, or is otherwise in control of the business; All employees who will have day-to-day operational management responsibility for the business or entity; and, If a publicly traded corporation, the designated license holder (designated agent) (must be over 21 and a resident of S.C.). All other principals must be listed also. If not a publicly traded corporation, list all stockholders. If a nonprofit organization, list all officers and directors of the organization. Name Home Address City State Zip Yr/Mo/Date of SC Residency Sex Social Security No. Federal Employer Identification No. Principal/Type: (use above #1-12) % of ownership Race Date of Birth Signature Have you as an individual, or as an organization in which you were a principal, had revoked or suspended in this state or any other state any license to sell beer, wine, or alcoholic liquors? Yes No If yes, attach explanation. Have you been convicted of a crime in South Carolina or any other state? Yes No If yes, attach explanation. Additional Space on Back. 44221018 American LegalNet, Inc. www.FormsWorkFlow.com File Number: Name Home Address City State Yr/Mo/Date of SC Residency Sex Social Security No. Principal/Type: (use above #1-12) Zip Race Date of Birth Federal Employer Identification No. % of ownership Signature Have you as an individual, or as an organization in which you were a principal, had revoked or suspended in this state or any other state any license to sell beer, wine, or alcoholic liquors? Yes No If yes, attach explanation. Have you been convicted of a crime in South Carolina or any other state? Yes No If yes, attach explanation. Name Home Address City State Yr/Mo/Date of SC Residency Sex Social Security No. Principal/Type: (use above #1-12) Zip Race Date of Birth Federal Employer Identification No. % of ownership Signature Have you as an individual, or as an organization in which you were a principal, had revoked or suspended in this state or any other state any license to sell beer, wine, or alcoholic liquors? Yes No If yes, attach explanation. Have you been convicted of a crime in South Carolina or any other state? Yes No If yes, attach explanation. Name Home Address City State Yr/Mo/Date of SC Residency Sex Social Security No. Principal/Type: (use above #1-12) Zip Race Date of Birth Federal Employer Identification No. % of ownership Signature Have you as an individual, or as an organization in which you were a principal, had revoked or suspended in this state or any other state any license to sell beer, wine, or alcoholic liquors? Yes No If yes, attach explanation. Have you been convicted of a crime in South Carolina or any other state? Yes No If yes, attach explanation. Name Home Address City State Yr/Mo/Date of SC Residency Social Security No. Principal/Type: (use above #1-12) Zip Sex Race Date of Birth Federal Employer Identification No. % of ownership Signature Have you as an individual, or as an organization in which you were a principal, had revoked or suspended in this state or any other state any license to sell beer, wine, or alcoholic liquors? Yes No If yes, attach explanation. Have you been convicted of a crime in South Carolina or any other state? Yes No If yes, attach explanation. 44222016 American LegalNet, Inc. www.FormsWorkFlow.com