Participation Form

2026 Participation Form

SCAC Debt Collection Programs
This notice certifies that the below named Claimant Agency (“Entity”) intends to participate in the South Carolina Department of Revenue’s Setoff Debt/GEAR Collection Program for the 2025 calendar year with and through the South Carolina Association of Counties.
Name of Entity*
Entity Code*
Entity will participate in:*

Setoff DebtGEAR
What type(s) of data file will you send?*

SCAC SoftwareExcelASCIICMS
If Excel or ASCII, do you want the data returned in the SCAC software?*

YesNo
Entity Coordinator*

First NameLast Name
Entity Coordinator Phone Number*
Please enter a valid phone number.
Entity Coordinator Email*
example@example.com
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Please list other staff in your entity that are authorized to receive information from us about data or payments. There must be at least one person, other than the above Coordinator, listed below.
Authorized Staff Name*

First NameLast Name
Authorized Staff Email*
example@example.com
Authorized Staff Phone Number*
Please enter a valid phone number.
Submit Additional Authorized Staff Names, Emails & Phone Numbers
This information will appear on Notice of Adjustment that DOR sends to debtors. Debtors WILL BE GIVEN and WILL CALL this phone number. This number MUST be answered.

The contact name can be an individual, a department name, or the name of the third party billing company.
Contact Name to send to SCDOR*
Phone Number to send to SCDOR*
Email to send to SCDOR*
example@example.com
Third Party Billing Company, IF APPLICABLE:
Third Party Billing Contact Name

First NameLast Name
Third Party Billing Company Name
Third Party Billing Phone Number
Please enter a valid phone number.
Third Party Billing Email
example@example.com
Third Party Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you want your third party billing company to have access to your secure folder?

YesNo
Do you prefer to have the Setoff and/or GEAR checks/payments sent to this company?

YesNo
Do you prefer to have other account information sent to this company? (bankruptcies, deceased status, wrong SSN, refund requests, etc.)

YesNo
I hereby certify on behalf of Entity that Entity satisfies and continues to satisfy all requirements of the Setoff Debt Collection Act, S.C. Code Ann. § 12-56-10 thru -120 and/or GEAR statute, S.C. Code Ann. § 12-4-580, to be eligible to participate in the Setoff Debt and/or GEAR programs. I further certify that all provisions of the Setoff Debt Collection Act will be met for each debt submitted to the Setoff Debt Program or GEAR Program.*

Clear
Date*

MonthDayYear
Date
Should be Empty:

2026 Participation Form