Form Wv/hcp3e - West Virginia Estimate Of Broad Based Health Care Related Taxes
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1WV/HCP3E
WEST VIRGINIA ESTIMATE OF BROAD
REV 10/07
BASED HEALTH CARE RELATED TAXES
CODE
TAXABLE
RATE
TAX
AMOUNT
DUE
FEIN
PERIOD
DUE
ENDING
DATE
MM DD
YYYY
MM DD
YYYY
NAME
TOTAL TAX DUE
SIGNATURE & DATE:
2 LESS CREDIT FROM PRIOR RETURNS
*H06100701A*
3 TAX DUE (LINE 1 MINUS LINE 2
MAKE CHECKS PAYABLE TO AND MAIL TO:
WV STATE TAX DEPARTMENT
INTERNAL AUDITING DIVISION
PO BOX 773 CHARLESTON, WV 25323-0773
PHONE (304) 558-6614
WV/HCP3E
WEST VIRGINIA ESTIMATE OF BROAD
REV 10/07
BASED HEALTH CARE RELATED TAXES
CODE
TAXABLE
RATE
TAX
AMOUNT
DUE
FEIN
DUE
PERIOD
DATE
ENDING
MM DD
YYYY
MM DD
YYYY
NAME
1 TOTAL TAX DUE
SIGNATURE & DATE:
2 LESS CREDIT FROM PRIOR RETURNS
*H06100701A*
3 TAX DUE (LINE 1 MINUS LINE 2
MAKE CHECKS PAYABLE TO AND MAIL TO:
WV STATE TAX DEPARTMENT
INTERNAL AUDITING DIVISION
PO BOX 773 CHARLESTON, WV 25323-0773
PHONE (304) 558-6614
WEST VIRGINIA ESTIMATE OF BROAD
WV/HCP3E
REV 10/07
BASED HEALTH CARE RELATED TAXES
CODE
TAXABLE
RATE
TAX
AMOUNT
DUE
FEIN
DUE
PERIOD
DATE
ENDING
MM DD
YYYY
MM DD
YYYY
NAME
1 TOTAL TAX DUE
SIGNATURE & DATE:
2 LESS CREDIT FROM PRIOR RETURNS
3 TAX DUE (LINE 1 MINUS LINE 2
*H06100701A*
MAKE CHECKS PAYABLE TO AND MAIL TO:
WV STATE TAX DEPARTMENT
INTERNAL AUDITING DIVISION
PO BOX 773 CHARLESTON, WV 25323-0773
PHONE (304) 558-6614
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