Form Wv/sev-401 - West Virginia Annual Severance Tax Return

WV/SEV-401

PAGE 2

(REV. 07/01)

SEVERANCE TAX COMPUTATION SCHEDULE

5.00

TOTAL TAX - Enter here and on Line 1 on Front of Return

Please answer all questions:

1. If you purchased this business in the past twelve (12) months, give the previous owner's name and ad-

dress:_______________________________________________________________________________________

__________________________________________________________________________________________________________

2. During the period covered by this return, did you: Quit business?________Sell or otherwise dispose of your

business?_________ Exact Date__________ b. If business was sold, give exact name and address of new

owner:____________________________________________________________________________________

_______________________________________________________________________________________________________

3. Address where your records are:_____________________________________________________________

__________________________________________________________________________________________

4. Principal place of business in West Virginia:__________________________________________________

5. Nature of business conducted (Describe in detail):_______________________________________________

_________________________________________________________________________________________

6. Give name and telephone number of preparer of this return:________________________________________

_________________________________________________________________________________________

7. Give name and account number of any additional business(es) operated in West Virginia by the reporting

taxpayer:__________________________________________________________________________________

__________________________________________________________________________________________

Under penalties of perjury, I declare that I have examined this return (including accompanying schedules and statements)

and to the best of my knowledge and belief it is true, and complete.

__________________________________________________________________________________________________________________________________________

(Signature of Taxpayer)

(Title)

(Date)

__________________________________________________________________________________________________________________________________________

(Person to Contact Concerning this Return)

(Telephone Number)

__________________________________________________________________________________________________________________________________________

(Signature of Preparer Other than Taxpayer)

(Address)

(Date)

Form Wv/sev-401 - West Virginia Annual Severance Tax Return - 2001 Page 2