Form Fs 102 – Fill Out and Use This PDF

Instructions

If you would like to make scheduled payments on your outstanding liability, complete this form. A payment agreement fee of $45.00 will be charged and added to your liability. If you have an open sales license, please contact the Taxpayer Service Center that serves your county to discuss your account. If your company qualifies for the Job Development Credit, you will be considered "not current" until all returns are filed and liabilities are paid in full.

A minimum down payment of 10% of the total balance due is required with this request. Refunds seized and applied to liabilities in the agreement will reduce the total agreement amount but will not substitute for regular scheduled payments. Penalty and interest will continue to accrue until paid in full. All future tax returns must be timely filed and paid for the agreement to remain in effect.

Your check must be made payable to the SC Department of Revenue. Please note your name and social security number on the check. You may be required to make future payments with certified funds or with electronic methods available through the Department. You will be notified if your request is approved, denied, or if additional information is needed.

Please check one of the following payment options:

Electronic Funds Withdrawal (EFW) allows funds to be automatically withdrawn from your checking or savings account on a pre-assigned date. Please attach your voided check or your micro specification sheet with this application for the account you request to be drafted.

Check, Certified Funds, or Electronic Funds Transfer (ePAY). Upon approval, coupons will be mailed to you. You may submit payment electronically by going to the agency's website at www.sctax.org, click on the link to EPay. EPay will allow you to provide payment by credit card (MasterCard or VISA) or by electronic funds withdrawal (EFW) from your bank account.

If you have any questions about installment agreements, call (803) 898-5000 or your local Taxpayer Service Center listed on the back of this form.

I hereby waive my right to appeal any outstanding Proposed Notice Of Assessment (PNOA) and/or Notice of Adjustment or Proposed Assessment (NOA) and consent to any PNOA or NOA being included in the requested payment agreement.

Signature

Date

I hereby give my consent to the South Carolina Department of Revenue to obtain a full credit report if necessary.

Signature

Date

Please mail this application and down payment to SCDOR, Central Office, Columbia, SC 29214-0217 or the Taxpayer Service Center that serves your county.

First Name (if joint, also give spouse's name) or Business Name	Last Name	Your Social Security Number
		FEI
Telephone Number and Contact Name
Mailing Address
City, Town	State	Zip Code
Place of Employment	Place of Employment (spouse)
Business Telephone Number or Daytime Phone Number	Business Telephone Number (spouse)
Type Tax and Periods Covered

Continued on back

1.The South Carolina Department of Revenue and its designated financial agents initiate an Electronic Funds Withdrawal (payment) entry to my financial institution account designated for payment of my South Carolina taxes owed, and

2.My financial institution to debit the entry to my account. I also authorize the financial institutions involved in the processing of my electronic payment of taxes to receive confidential information necessary to answer inquiries and resolve issues related to my payment.

Under the items of this authorization, I can revoke this authorization by notifying the South Carolina Department of Revenue no later than two business days prior to the withdrawal (settlement) date. I understand that notification must be made in writing and faxed to Electronic Services at (803) 898-5339.

Your Signature	Date
Spouse's Signature	Date

Taxpayer Service Centers

The South Carolina Department of Revenue is ready to assist you at 6 locations around the state. You will find the address, telephone numbers and counties served for each location listed below.

Columbia Main Office:	301 Gervais Street	Greenville Service Center:	211 Century Drive
	P.O. Box 125		Suite 210-B
	Columbia, S.C. 29214		Greenville, S.C. 29607
	Phone: 803-898-5000		Phone: 864-241-1200
	Fax: 803-898-5822		Fax: 864-232-5008
Charleston Service Center:	3 Southpark Circle	Myrtle Beach Office:	1330 Howard Parkway
	Suite 202		Myrtle Beach, SC 29577
	Charleston, S.C. 29407
	Phone: 843-852-3600
	Fax: 843-556-1780
Florence Service Center:	1452 West Evans Street	Rock Hill Service Center:	454 South Anderson Road
	P.O. Box 5418		Business and Technology Center
	Florence, S.C. 29502		Suite 202
	Phone: 843-661-4850		P.O. Box 12099
	Fax: 843-662-4876		Rock Hill, S.C. 29731
			Phone: 803-324-7641
			Fax: 803-324-8289

COLUMBIA	CHARLESTON	GREENVILLE	FLORENCE	ROCK HILL
Aiken	Beaufort	Abbeville	Chesterfield	Cherokee
Allendale	Berkeley	Anderson	Clarendon	Chester
Bamberg	Charleston	Laurens	Darlington	Kershaw
Barnwell	Colleton	Oconee	Dillon	Lancaster
Edgefield	Dorchester	Pickens	Florence	York
Greenwood	Georgetown	Spartanburg	Horry	Fairfield
Lexington	Hampton	Union	Lee
McCormick	Jasper	Greenville	Marion
Newberry			Marlboro
Orangeburg			Williamsburg
Richland			Sumter
Saluda
Calhoun