Form Wv/cst-Af1 - Affidavit For An Individual Filing A Claim Of Refund For Consumers Sales And Service Tax Or Use Tax - 2011

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W
V
s
t
D
WV/CSt-af1
est
irginia
tate
ax
epartment
(rev. 11/11)
AffidAvit for An individuAl filing A ClAim of refund
for Consumers sAles And serviCe tAx or use tAx
See requirements on reverse side
nAme
street Address
City, stAte, Zip Code
telephone number
State of WeSt Virginia
County of________________________________.
i, ____________________________________ , being duly sworn, depose and say that on ____________________
(name)
(Date)
i purchased from _________________________________________________________________________________
(Business name and address)
the following tangible personal property or services: _________________________________________________
this purchase is exempt from Consumers Sales and Service tax or use tax for the following reason:
i was charged $ _____________________ Consumers Sales and Service or use tax on this purchase and
the tax has not been refunded to me. as proof, i have enclosed a copy of my invoice showing the date of
purchase and the amount of tax paid.
_____________________________________
___________________
(Signature)
(Date)
taken, subscribed and sworn before me this _____________ day of ________________________, 20 ________.
My commission expires on ________________________________________________________________________.
(notary Seal)
____________________________________________
(notary Public)

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