Annual Return Of Broad Based Health Care Related Taxes
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1
2
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4STATE OF WEST VIRGINIA
State Tax Department, Tax Account Administration Div
P.O. Box 773
Charleston, WV 25323-0773
Craig A. Griffith, Tax Commissioner
Earl Ray Tomblin, Governor
Name
Address
Account #:
City
State
Zip
ANNUAL RETURN OF BROAD BASED HEALTH CARE RELATED TAXES
WV/HCP-3A
rtL080 v.10-Web
Save the stamp and your time. You can now view, file and pay this tax at https://mytaxes.wvtax.gov
More taxes will be available for online access in the future.
Period Ending:
Due Date:
Extension Date:
M
M
D
D
Y
Y
Y
Y
Method of Accounting
ACCRUAL
CASH
FINAL
AMENDED
(Check One)
COMPUTATION OF TAX
1.
Total Annual Tax Due from Schedule D Line 4
.
2.
Combined Annual Medical Malpractice Credit from Prior Year (Carry Forward)
.
3.
Remaining Tax Due (Line 1 minus Line 2)
.
4.
Credit to be Carried Forward (This Credit is not Refundable)
.
5.
Total Estimated Payments for the Period Covered by this Return
.
6. Credit for Overpayment from Prior Year Annual Return
.
7. Total Payments and Credits (Add Lines 5 and 6)
.
8. Total Tax Due (Line 3 minus Line 7 - If Line 7 is Greater than Line 3 Enter 0)
.
9. Overpayment Amount (Line 7 minus Line 3) If Line 3 is greater than Line 7, enter 0
.
10.
Amount of Line 9 to be Credited to Next Year's Tax
.
11.
Amount of Line 9 to be Refunded (Line 9 minus Line 10)
.
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)
(Name of Taxpayer - Type or Print)
(Title)
(Date)
(Person to Contact Concerning this Return)
(Telephone Number)
(Signature of preparer other than taxpayer)
(Address)
(Date)
MAIL TO: WEST VIRGINIA STATE TAX DEPARTMENT
Tax Account Administration Div
P.O. Box 773, Charleston, WV 25323-0773
FOR ASSISTANCE CALL (304) 558-3333 TOLL FREE (800) 982-8297
For more information visit our web site at:
G
1
6
2
0
0
8
0
1
W
File online at https://mytaxes.wvtax.gov
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