Form Wv/bus-App - Application To Secretary Of State For Name Reservation Page 3

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SECTION A: TO REGISTER WITH THE WEST VIRGINIA STATE TAX DEPARTMENT, CONTINUED

Page 2 of 4

9. BEER BARREL TAX: Will you hold a license to sell beer to licensed beer distributors? ........................................... Yes

( 9)

(9A)

A. Will you hold a license to sell beer to licensed beer retailers? ............................................................................................. Yes

10. BUSINESS AND OCCUPATION TAX: Will you be providing the following: Public Utilities? ........................................ Yes

(10)

(10A)

A. Generating Electric Power for sale? .................................................................................................................................. Yes

(10B)

B. Operate a natural gas storage reservoir ........................................................................................................................ Yes

11. TOBACCO PRODUCTS TAX: Will you stamp and sell cigarettes at the wholesale level? ...................................... Yes

(11)

(11A)

A. Will you sell other tobacco products at the wholesale level? ........................................................................................ Yes

(11B)

B. Will you sell both cigarettes and other tobacco products at the wholesale level? ....................................................... Yes

C. Will you sell cigarettes at the retail level? ....................................................................................................................... Yes

(11C)

(11D)

D. Will you sell other tobacco products at the retail level? ................................................................................................. Yes

(11E)

E. Will you sell both cigarettes and other tobacco products at the retail level? ................................................................. Yes

12. CONSUMERS SALES/SERVICE TAX: Do you have a business location in WV from which you will make retail sales

(12)

or do any service or maintenance work? .......................................................................................................................... Yes

13. CORPORATION NET INCOME/BUSINESS FRANCHISE TAX: Are you registered with the

(13)

West Virginia Secretary of State? ........................................................................................................................................ Yes

(13A)

A. Will you file your corporation tax returns in West Virginia on a consolidated basis under your parent corporation? ..... Yes

B. If yes, enter parent's FEIN, name and address:

(13B)

(13C)

C. If S corporation, enter first year to which subchapter S status applies: ..............................................................................

(13D)

D. If partnership, enter date elected not to be treated as a partnership under Section 761 of the Internal Revenue Code ............

14. MOTOR FUEL EXCISE TAX: Will you purchase, sell or transport fuel in West Virginia? If yes, you must complete

(14)

West Virginia Motor Fuel Excise Tax License Application. .................................................................................................. Yes

(14A)

A. Will you sell tax paid gasoline at the retail level? ............................................................................................................ Yes

(14B)

B. Will you sell tax paid special fuel at the retail level? ....................................................................................................... Yes

(14C)

C. Will you operate aircraft, watercraft or locomotives which haul freight or passengers within West Virginia? .......... Yes

(15)

15. LIQUOR/WINE RETAIL TAXES: As a retailer, will you hold a license to sell liquor and/or wine by the bottle? .... Yes

(Does not apply when sold in clubs, bars or restaurants).

16. SEVERANCE TAX: Will you hold title to or have an economic interest in the activity of severing, extracting, reducing

(16)

to possession and producing for sale, profit or commercial use, any natural resource product? .................................... Yes

(16A)

A. Will you produce or process coal only? ......................................................................................................................... Yes

(16B)

B. Will you produce timber? ................................................................................................................................................. Yes

(17)

17. SOFT DRINK TAX: Will you sell bottled/canned soft drinks/syrups and/or powders? If yes, in what capacity? .... Yes

(17A)

A. Bottler? ............................................................................................................................................................................ Yes

(17B)

B. Wholesale? ...................................................................................................................................................................... Yes

(17C)

C. Will you purchase soft drinks, Excise Tax not paid, from a bottler/wholesaler? .......................................................... Yes

(17D)

D. Will you purchase soft drinks, Excise Tax paid, from a bottler/wholesaler? ................................................................ Yes

18. TELECOMMUNICATIONS TAX: Will you be selling or furnishing local telegraph, telephone or other telecommunication

(18)

services subject to regulation from Public Service Commission and not in competition with other firms? ........................ Yes

(19)

19. USE TAX: Will you make purchases from outside of West Virginia for use in West Virginia (other than for resale)? Yes

A. Will you have salesmen or property located within West Virginia and/or advertise locally and/or deliver from out-of-state

into West Virginia in your own vehicles? ................................................................................................................................. Yes

(19A)

B. If a foreign retailer will you be collecting West Virginia use tax on sales or services to West Virginia customers? .. Yes

(19B)

20. WINE LITER TAX: Have you registered with the ABCC to sell wine to licensed wine distributors? ......................... Yes

(20)

A. To licensed wine retailers? ............................................................................................................................................. Yes

(20A)

B. Will you sell wine products to West Virginia registered wine suppliers? ..................................................................... Yes

(20B)

21. WITHHOLDING TAX: Will you have West Virginia employees? .................................................................................. Yes

(21)

A. Date you began or will begin withholding West Virginia income tax from employees ..................................................

(21A)

B. Number of employees subject to West Virginia income tax; Do not include owner or partners: ................................

(21B)

C. Will you withhold more than $250.00 of West Virginia income tax per month? ............................................................. Yes

(21C)

D. Are you an out-of-state business registering to report withholding tax only? ............................................................. Yes

(21D)

22. HEALTH CARE TAXES:

A. Are you a behavioral health center ? ............................................................................................................................. Yes

(22A)

B. Will you provide a health care service (includes ambulance)? ...................................................................................... Yes

(22B)

If your gross income is over $4,000.00 in all states for the previous filing year, a $30.00 registration fee is due with this application.

OR THIS APPLICATION TO BE VALID AND TO AVOID DELAY IN PROCESSING

ALL PAGES MUST BE COMPLETED AND APPLICATION SIGNED

MAIL APPLICATION TO: West Virginia State Tax Department P.O. Box 11425, Charleston, WV 25339

This application may be photocopied as proof

of registration until your Certificate(s) are issued.

*B29080602A*

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