Free SPECIAL PURPOSE DISTRICT NOTIFACATION FORM - South Carolina

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Office of the South Carolina Secretary of State
Please return form to: Post Office Box 11350 Columbia, SC 29211 Phone: (803) 734-1796 Fax: (803) 734-1604 www.scsos.com

SPECIAL PURPOSE DISTRICT NOTIFICATION FORM
1. 2. 3. Legal Name of District: ___________________________________________________________________________ County(ies) District is located in: ____________________________________________________________________ Address: ________________________________________________________________________________________
(If no permanent address, please list the address, name and telephone number of agent)

Name of Agent: _________________________________ 4.

Phone Number: _________________________________

Services Provided: ________________________________________________________________________________

5. General description of geographical boundary (Please attach the legal description):_____________________________ _______________________________________________________________________________________________ 6. 7. Citation of statutory authority (Please attach copy): ______________________________________________________ Date of Origin: ___________________________________________________________________________________

8. Tax rate or fee charged: ____________________________________________________________________________ 9. Names of members of governing body and expiration date of current term in office (Please indicate expiration date in the format MM/DD/YYYY.): EXP. DATE NAME ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ _______________________________ _______________________________ _______________________________

10. Method of selecting members of governing body: _______________________________________________________ 11. Financial information for prior fiscal year (Do not send financial statements): a. Fiscal Year Ending (MM/DD/YYYY): ____________________________________________________________ b. Total revenues by source including investment earnings: ______________________________________________ c. Total Expenditures: ___________________________________________________________________________ d. Total Indebtedness (indicate bonded or otherwise): __________________________________________________ e. Total Investments (attach list of individual amounts, location, and rates of interest): ________________________

12. Person completing form: __________________________________________ Title: __________________________ Mailing Address: ________________________________________________________________________________ Phone Number: _____________________________ Email Address ________________________________________ 13. County Auditor's Signature:_________________________________________________ Date:__________________ IF THE SPACE ON THIS FORM IS NOT SUFFICIENT, PLEASE ATTACH ADDITIONAL PAGES CONTAINING A REFERENCE TO THE APPROPRIATE SECTION.