Form Wv/eotc-A - Application For West Virginia Economic Opportunity Tax Credit For Investments Placed In Service On Or After January 1, 2003

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Application for West Virginia
WV/EOTC-A
Economic Opportunity Tax Credit
Rev. 4/09
For Investments Placed In Service On Or After January 1,
2003
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BUSINESS NAME
IDENTIFICATION NUMBER
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TAX Year
TO
YYYY
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DD
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YYYY
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PERSON TO CONTACT CONCERNING THIS RETURN
NAME OF TAXPAYER
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ADDRESS
PREPARER’S EIN
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CITY OR POST OFFICE
ZIP CODE
STATE
DAYTIME TELEPHONE
Application is hereby made to the Tax Commissioner of West Virginia for allowance of Economic Opportunity Tax Credit with
respect to qualified investment property placed in service or use during Applicant’s tax year, as indicated above, and the new
jobs created by the Applicant that are directly attributable to the qualified investment property and that are filled by persons who
are domiciled in this State.
1. a.
Application Status (Check Only One):
One Year Investment, One Taxpayer
a.)
Multiple Year Investment, One Taxpayer - Must receive Certification From Tax Commissioner
b.)
Note: An application must be filed for each year in which investment for purposes of the Economic Opportunity Tax Credit
is placed in service or use. Additionally, the application must be approved by the State Tax Commissioner before any credit
may be claimed.
b.
Type of Credit:
Regular Credit
Headquarters Relocation
Small Business
Specified High Technology Manufacturer
Other (See Instructions)
2 a.
Investment:
Total Investment
Qualified Investment
Year-1 (ending)
Amount $
$
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Year-2 (ending)
Amount $
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$
Year-3 (ending)
Amount $
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b.
Locations(s) of Investment in West Virginia
c.
General Description of Qualified Investment:
Narrative:

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