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Form Wv/it-105.1 - Specifications For Filing Information Forms Annual 1099-R, 1099 Misc And W2-G On Electronic Media Page 5

WV/IT-105.1

Rev12/2010

West Virginia State Tax Department

Transmitter Summary Report

Tax Year _________

Transmitter Name__________________________

FEIN_____________________________

Address__________________________________

Contact___________________________

City, State & Zip___________________________

Phone____________________________

Media:

CD Rom

Computer Manufacturer and Model used to create report _____________________

List all payers included in this filing (attach additional sheets if needed)

Name

FEIN

# of forms

* File name must be 1099report.txt or 1099report.zip and open to 1099report.txt. Any other file

name will be rejected and returned.

Note: For each CD ROM submitted, please complete a separate Media Transmitter Report.

To ensure against damage during shipping package CD ROMs appropriately.

Mail all completed reports along with Form WV/IT-103 Annual Reconciliation and media to:

Mail all completed reports and media to:

Mailing Address:

Courier or Overnight Deliveries (ONLY):

West Virginia State Tax Department

TAAD/ Withholding

Revenue Center / Withholding

PO Box 3943

1001 Lee Street East

Charleston, WV 25339-3943

Charleston, WV 25301-1725

Form Wv/it-105.1 - Specifications For Filing Information Forms Annual 1099-R, 1099 Misc And W2-G On Electronic Media Page 5