SC Transferor Affidavit Tax Lien Inapplicable 1

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SC Transferor Affidavit Tax Lien Inapplicable 1

Form Document
V 1



The undersigned transferor hereby certifies as follows:

1.         This affidavit is being given in connection with a transfer of property to assure the           transferee that the Department will not assert that Code Section 12-54-124 placed            a lien against the assets in the hands of the transferee, and if applicable, the            Department will not refuse to issue a license and will not revoke a license based             upon Code Section 12-54-124.  This affidavit issued for purposes of Code Section       12-54-124 is valid for 30 days from the date signed.  it is understood that his        affidavit does not protect the transferee from a lien placed on the assets prior to   the transfer by other statutory or judicial means, or relieve the transferor of his    liabilities to pay all of its taxes or file all applicable returns, and that it does not    protect the transferee from the Department refusing to issue a license, or revoking       a license, for any other reason.  For example, the transferee is not protected from a        lien existing on the property due to nonpayment of real property taxes.

2.         The undersigned is the transferor of the assets described in the attached             description.

3.         The Tranferor's name is _____________________________________________

4.         The Tranferor's address is ___________________________________________

5.         The Transferor's taxpayer identification number is _________________________

6.         Date of Transfer __________________________________________________

7.         The Transferee's name is ____________________________________________

8.         The Transferee's address is __________________________________________


I hereby certify the following concerning the transfer (check one of the below):

______ The assets transferred are not business assets.

______ Less than a majority of the business assets, based on fair market value, are being transferred in this and other related or planned transfers.

The undersigned authorizes the delivery and disclosure of this affidavit to the South Carolina Department of Revenue and acknowledges that any false statement contained herein is punishable by fine, imprisonment, or both, recognizing that I am subject to the criminal penalties under Code Section 12-54-124(B)(6)(a(i)), I declare that I have examined this affidavit and to the best of my knowledge and belief it is true, correct, and complete.


____________________________________                        ________________________

Signature                                                                                  Date






                                                            )                       ACKNOWLEDGMENT

COUNTY OF CHARLESTON            )                              (Corporation)


The foregoing instrument was acknowledged before me this ___ day of ___________, ________ by (name of officer, title of officer) of (name of corporation) a (state or place of incorporation) corporation, on behalf of the corporation.




Notary Public for South Carolina

My Commission Expires:


No guidelines are available for this form at this time.