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 1350                                     STATE OF SOUTH CAROLINA 
                                          DEPARTMENT OF REVENUE                                                  FS-102 
                                                                                                                 (Rev. 2/17/23) 
 dor.sc.gov                               PAYMENT PLAN REQUEST                                                    2094
 STOP! The fastest, easiest way to complete this application is online. Get started at dor.sc.gov/PayPlan.
 Businesses must contact us before completing this form. Find phone numbers and locations at dor.sc.gov/contact.
                A nonrefundable $45.00 Payment Plan fee will be applied to Income Tax balances.
 How will you pay?  (check one)                                                                          Date
 Pay using your bank information. No down payment required. Payments are 
 automatically drafted on the date you select. Enter your banking information below.                     SSN/FEIN
 Pay by check or money order (made payable to SCDOR) or online at dor.sc.gov/pay. 
 A down payment is required for this payment option and payment must be attached: 
   · 20% of your total balance for Individual Income Tax payment plans                                   Email
   · 10% of your total balance for GEAR payment plans 
First and last name or Business name
                                                                                                         Phone
Mailing Address
                                                                                                         Your total balance due
 Checking       Savings             IMPORTANT: If accepted, we will process your  payment on your chosen 
                                          due date and send you your payment schedule.                   Your monthly payment amount  
Bank name (No reloadable debit accounts.)                                                                (use table below to determine)

Routing number (Account must be in US.)
                                                                                                         What day of the month should we 
                                                                                                         process your payment? Choose a 
Account number                                                                                           day between the 1st and 28th.

Payment Plan Terms 
Individual Taxes and GEAR                                                               
 Balance due                        Maximum pay plan length The length of time you have to pay is based on your
 $0 - $999                          12 month payment plan   balance due. Calculate your monthly payment by dividing
 $1,000 - $4,999                    24 month payment plan   your Balance due by the number of months listed in the
 $5,000 - $9,999                    36 month payment plan   corresponding Maximum pay plan length column.
 $10,000 and above                  48 month payment plan
By submitting this request, I understand:
 · The SCDOR will withdraw funds as outlined above every month until my balance is paid. 
 · The SCDOR will cancel this agreement if I miss a payment or accrue more debt. 
 · Penalty and interest will accrue until my balance is paid, which may increase the number of monthly payments. 
 · I cannot appeal this balance after submitting a payment plan, and I will receive an immediate assessment. 
 · My balance due includes the amount due on the return, late fees, proposed assessments, assessments, and liens. 
 · The SCDOR may hold my state or federal Individual Income Tax refund and apply it to my balance due. 
 · The SCDOR may file and record liens for all amounts owed and add the cost to my balance. 
By submitting this request, I authorize:
 1.  The SCDOR and its designated financial agents to draft payments from my bank based on the terms above, and 
 2.  The financial institutions involved in processing to receive confidential information related to my payment. 

You can cancel this authorization up to five business days before your payment draft date. You must email the 
cancellation to PPARequest@dor.sc.gov.

   Your Signature                         Spouse's Signature (If applicable)                                  Date

Mail your completed request to SCDOR, Payment Plan, PO Box 125, Columbia, SC 29214-0217. 
Questions: Contact us at PPARequest@dor.sc.gov
 20941027