Monthly Estimate Of Severance And Business Privilege Taxes For Providers Of Health Care Items And Services Form

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STATE OF WEST VIRGINIA
State Tax Department, Tax Account Administration Div
P.O. Box 773
Charleston, WV 25323-0773
Earl Ray Tomblin, Governor
Craig A. Griffith, Tax Commissioner
MONTHLY ESTIMATE OF SEVERANCE AND BUSINESS PRIVILEGE TAXES
WV/SEV-400H
FOR PROVIDERS OF HEALTH CARE ITEMS AND SERVICES
rtL086 v.9-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.
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:
File online at https://mytaxes.wvtax.gov
PLEASE CUT HERE. USE BLUE OR BLACK INK TO COMPLETE VOUCHER. DO NOT WRITE IN BARCODE AREA.
WV/SEV-400H
rtL086 v.9-Web
MONTHLY ESTIMATE OF SEVERANCE AND BUSINESS PRIVILEGE TAXES
FOR PROVIDERS OF HEALTH CARE ITEMS AND SERVICES
Account ID #
Period Ending:
Due Date:
1.
Taxable Amount
.
2.
0.05
Rate
3.
.
Total Amount of Tax Due (Multiply Line 1 by Line 2)
4.
.
$41.67 Per Month Annual Exemption
5.
.
Credit for Overpayment from Prior Year Annual Return
6. Total Tax Due (Line 3 minus Lines 4 and 5)
.
Name
Address
SIGNATURE
DATE
City
State
Zip

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