Form Wv/brt-814 - Application For Refund Of Business License Registration Fee
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1WEST VIRGINIA
WV/BRT-814
Rev. 9/97
DEPARTMENT OF TAX & REVENUE
INTERNAL AUDITING DIVISION
P. O. BOX 2666
CHARLESTON, WEST VIRGINIA 25330
APPLICATION FOR REFUND OF BUSINESS LICENSE REGISTRATION FEE
(WEST VIRGINIA CODE 11-12)
West Virginia Identification Number .............
Business Name ..........................................
Address ......................................................
1. Period for which Refund is requested: ............................................................................ 1.
Note: The Business License Registration Period
covers fiscal year: July 1 - June 30
2. Gross income of business for the license period that refund is being requested .............. 2.
3. Refund requested .......................................................................................................... 3.
4. Reason for requesting refund:
TAX DEPARTMENT USE ONLY
CAUTION: Read this application before signing. Pre-
senting a fraudulent claim constitutes a felony.
Refund Class
I certify all information hereon to be true and accurate
to the best of my knowledge.
Transaction Number
SIGNATURE
License Year
Amount of Refund $
TITLE
DATE
Sworn to and subscribed before me this ______ day of ________
Approved By
Seal of Officer
Date Approved
Taking Affidvit__________________________________________
Notary Public
Serial Number
County of _______________________ State of _______________
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Parent category: Business