The undersigned nonresident taxpayer on oath, being first duly sworn, hereby certifies as follows:

1. Owner, Partner(s) or Corporate Name of Nonresident Taxpayer: ____________________________________________________________________
2. Trade Name (Doing Business As): ____________________________________________________________________
3. Mailing Address:
4. Federal Identification Number: ____________________________________
5. ______ Hiring or Contracting with:
Name: __________________________________________________
Address: ________________________________________________
6. I hereby certify that the above-named nonresident taxpayer is currently registered with (check the appropriate box):
______ The South Carolina Secretary of State or
______ The South Carolina Department of Revenue
Date of Registration: ____________________________________________
7. I understand that by this registration, the above-named nonresident taxpayer has agreed to be subject to the jurisdiction of the South Carolina Department of Revenue and the courts of South Carolina to determine its South Carolina tax liability, including estimated taxes, together with any related interest and penalties.
8. I understand the South Carolina Department of Revenue may revoke the withholding exemption granted under Code Section 12-9-310 at any time it determines that the above- named nonresident taxpayer is not cooperating with the Department in the determination of its correct South Carolina tax liability.

The undersigned understands that any false statement contained herein could be punished by fine, imprisonment or both.

Recognizing that I am subject to the criminal penalties under Code Section 12-54-40 (b)(6)(f)(5), I declare that I have examined this affidavit and to the best of my knowledge and belief, it is true, correct and complete.

__________________________________________________ (Seal) ______________
(Signature of Owner, Partner or Corporate Officer)              Date
If Corporate officer state title: __________________________________
(Name - Please Print)