Form Wv/cem-1 - Registration Application For Cemeteries

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WEST VIRGINIA DEPARTMENT OF TAX AND REVENUE
INTERNAL AUDITING DIVISION
WV/CEM-1
REGISTRATION UNIT
REV. APRIL 1998
P.O. BOX 2666, CHARLESTON, WEST VIRGINIA 25330-2666
REGISTRATION APPLICATION FOR CEMETERIES
REGISTRATION YEAR
WEST VIRGINIA IDENTIFICATION NUMBER, NAME AND ADDRESS
CHECK TYPE
FEIN
JULY 1, _____
1
ANNUAL
NAME
THROUGH
REGISTRATION
ADDRESS
JUNE 30,_____
$200.00
CITY ST ZIP
Name and Mailing Address
2
OWNERSHIP OR
DUE DATE
COMPLIANCE
NAME
AGENT CHANGES
JULY 1,_____
ADDRESS
$100.00
CITY ST ZIP
On or after July 1, 1993, no person, partnership, firm or corporation may engage in the business of operating a cemetery company
in this State without having first paid an annual registration fee of two hundred dollars ($200.00)and filing with the Tax Commissioner
certain information, which shall include the name and addresses of all officers, owners and directors of the cemetery company and the
name of the designated compliance agent. The cemetery company shall notify the Tax Commissioner of any changes in the information
required to be filed within ninety days of the date on which the change occurs. A new filing shall also be required if there is a change
in the ownership of the cemetery company or if there is a change in the name of the compliance agent designated by the cemetery
company. The cemetery company shall pay an additional fee of one hundred dollars ($100.00)when reporting such changes. This also
includes certain funeral homes and sellers of memorials. Questions on reverse side of application must be completed.
LIST NAME AND ADDRESS OF ALL OFFICERS, OWNERS, DIRECTORS AND DESIGNATED COMPLIANCE AGENT
NAME
P.O. BOX/STREET ADDRESS, CITY, STATE, ZIP CODE
OFFICER:
OFFICER:
OWNER:
OWNER:
DIRECTOR:
DIRECTOR:
COMPLIANCE AGENT:
MAKE A PHOTOCOPY OF THE APPLICATION BEFORE MAILING IT IN THE ENVELOPE PROVIDED. THE
PHOTOCOPY WILL BE USED AS PROOF OF REGISTRATION UNTIL YOUR CERTIFICATE IS ISSUED
(APPROXIMATELY 3 WEEKS). FOR ASSISTANCE PLEASE CALL THE TAXPAYER SERVICES DIVISION AT: (304)
558-3333 OR TOLL FREE WITHIN WEST VIRGINIA AT: 1-800-WVA-TAXS (1-800-982-8297).
I certify this report to be true and correct:
DO NOT USE THIS SPACE
_____________________________________________
Signature
____________________________ ________________
Title
Date

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