License Application To Sell Raffle Boards And Games printable pdf download

STATE OF WEST VIRGINIA

State Tax Department, Charitable Bingo/Raffle Unit

P.O. Box 1143

Charleston, WV 25324-1143

Craig A. Griffith, Tax Commissioner

Earl Ray Tomblin, Governor

Name

Address

Account #:

City

State

Zip

LICENSE APPLICATION TO SELL RAFFLE BOARDS AND GAMES

WV/RAFBRD-1

rtL181 v.3-web

NOTE: This return has been redesigned. To avoid delays in the processing of this return, DO NOT use any older

forms you may have. For information regarding the State Tax Department’s new computer system, visit our

website at

Registration Year:

Due Date:

Check Type:

Wholesaler or Distributor

Manufacturer

Manufacturer and Distributor

Under West Virginia Code § 47-23 Wholesalers, Distributors or Manufacturers making sales to West Virginia Retailers

must have a current Raffle Boards and Games License.

The annual fee is $500.00 - Amount Enclosed

Also you must be registered to do business in the State of West Virginia pursuant to the provisions of West Virginia Code § 11-12.

If you have not registered to do business in West Virginia, please review the information in the enclosed booklet, complete the

Application for Registration Certificate (WV/BRT-801) and mail it with this application.

IF YOU ARE A NONRESIDENT SUPPLIER OF RAFFLE BOARDS AND GAMES TO WEST VIRGINIA

RETAILERS, YOU MUST DESIGNATE A RESIDENT AGENT UPON WHOM NOTICE OF PROCESS

MAY BE SERVED. PLEASE FURNISH THE FOLLOWING INFORMATION:

RESIDENT AGENT:

TELEPHONE:

STREET:

CITY:

STATE:

ZIP CODE:

Complete and return this application and $500.00 remittance.

Make checks payable to West Virginia State Tax Department

Should you have any questions, please contact the Charitable Bingo/Raffle Unit at (304) 558-8510

Make a photocopy of this application for your records before mailing it.

Sign Your Return

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)

(E-mail Address)

(Signature of preparer other than taxpayer)

(Address)

(Date)

MAIL TO: WEST VIRGINIA STATE TAX DEPARTMENT

Charitable Bingo/Raffle Unit

P.O. Box 1143, Charleston, WV 25324-1143

FOR ASSISTANCE CALL (304) 558-8510

For more information visit our web site at:

File online at https://mytaxes.wvtax.gov

License Application To Sell Raffle Boards And Games

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