Form Wvhcp3e - West Virginia Estimate Of Broad Based Health Care Related Taxes

*H06090601W*

WVHCP3E

REVISED 9-06

WEST VIRGINIA ESTIMATE OF BROAD BASED HEALTH CARE RELATED TAXES

INTERNAL AUDITING DIVISION PO BOX 773 CHARLESTON, WV 25323-0773 PHONE (304) 558-8617

FEIN:

CODE

TAXABLE AMOUNT

RATE

TAX DUE

PERIOD ENDED:

DUE DATE:

NAME & ADDRESS

1. TOTAL AMOUNT OF TAX DUE

2. LESS CREDIT FROM PRIOR RETURNS

____________________________________

________________

3. TAX DUE

SIGNATURE OF PREPARER

DATE

(LINE 1 MINUS LINE 2)

CUT HERE ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------