Form It-141 - West Virginia Fiduciary Income Tax Return (Page 2 of 3) in pdf

*P35200602W*

SCHEDULE A - BENEFICIARY INFORMATION AND NONRESIDENT WITHHOLDING

ATTACH ADDITIONAL COPIES OF SCHEDULE AS NEEDED

NAME AND ADDRESS OF EACH BENEFICIARY

NAME

STREET OR OTHER MAILING ADDRESS

CITY

STATE

ZIP CODE

COMPUTATION OF WEST VIRGINIA NONRESIDENT BENEFICIARIES WITHHOLDING TAX

(A)

WEST VIRGINIA

(E)

(F)

(G)

(H)

FILING METHOD OF BENEFICIARY

IF NRW-4

ATTACHED OR

BENEFICIARY

SOCIAL

PREVIOUSLY

SHARE OF WV

TAX

(B)

(C)

(D)

SECURITY NUMBER

RESIDENT

COMPOSITE

NONRESIDENT

FILED

INCOME

RATE

WITHHELD

6 TOTALS

COLUMN I

COLUMN II AMOUNT

SCHEDULE B - WEST VIRGINIA FIDUCIARY MODIFICATIONS

ALLOCATED TO

TOTAL

ESTATE OR TRUST

ADDITIONS:

Interest Income on State and Municipal bonds, other than West Virginia ..............

If This

Lump sum distribution (federal Form 4972) .......................................................

is a

Federal exemption (Form 1041, line 20) ................................................................

Simple

Other additions - state nature and source

Trust

1. Total additions (add lines a through d) ..........................................................................

Having

SUBTRACTIONS:

Interest income on US obligations specifically exempt from State tax ...................

Taxable

600 00

West Virginia exemption .......................................................................................

Income,

Other subtractions - state nature and source

OMIT

2. Total subtractions (add lines a through c) .....................................................................

Col. II

3. Net fiduciary modifications (line 1 minus line 2) ............................................................

4. Estate or trust share of net fiduciary modifications (line 1 minus line 2,

Col. II, enter here and on page 1, line 2 ) ......................................................................

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge

Sign

and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer is based on all information of which preparer has any knowledge.

Here

Date

Signature of fiduciary or officer representing fiduciary

Date

Paid

Preparer's

signature

Use Only

Firm's name (or

Phone no. (

)

yours if self-employed),