Form Wv/sn-4 - Application For Refund Of Sparklers And Novelties Registration Fee printable pdf download

Form Wv/sn-4 - Application For Refund Of Sparklers And Novelties Registration Fee

WEST VIRGINIA

WV/SN-4

Orig. 8/98

DEPARTMENT OF TAX & REVENUE

INTERNAL AUDITING DIVISION

P. O. BOX 2666

CHARLESTON, WEST VIRGINIA 25330

APPLICATION FOR REFUND OF SPARKLERS AND NOVELTIES REGISTRATION FEE

(WEST VIRGINIA CODE 11-12)

West Virginia Identification Number ............

Business Name ..........................................

Address ......................................................

1. Period for which Refund is requested: .......................................................................... 1.

Note: The Sparklers and Novelties Registration Period

covers fiscal year: July 1 - June 30

2. Refund requested ......................................................................................................... 2.

3. Reason for requesting refund:

PLEASE RETURN THE ORIGINAL CERTIFICATE TO SELL

SPARKLERS AND NOVELTIES WITH YOUR REFUND REQUEST.

TAX DEPARTMENT USE ONLY

CAUTION: Read this application before signing.

Presenting a fraudulent claim constitutes a felony.

Refund Class

I certify all information herein 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 _______________

Form Wv/sn-4 - Application For Refund Of Sparklers And Novelties Registration Fee