Form Wv/it-105 - West Virginia State Tax Department W-2 And 1099-R Transmitter Summary Report Page 4

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WV/IT-105
Rev 11/07
West Virginia
State Tax Department
W-2 and 1099-R Transmitter Summary Report
Tax Year_______
Transmitter Name
WV FEIN
Address
Contact Person
City,State & Zip
Phone # & Estension
MMREF-1 Format 512 bytes only
Data:
W-2
1099-R
Media:
CD Rom *
Diskette
3480/3480E or 3490/3490E Cartridge
Computer Manufacturer and Model used to create report______________________
(attach additional sheets if needed)
List all employers included in this filing
Employer Name
FEIN
# of W-2s
* File name must be w2report with no extentions. Any other file name will be rejected and returned.
Note: For each type of media submitted, please complete a separate Magnetic Media Transmitter Report. Pack-
age cartridges and diskettes appropriately to ensure against damage during shipping. Mail all completed reports
along with two copies of Form WV/IT-103 Annual Reconciliation of Withholding and magnetic media to:
• Mailing Address:
• Courier or Overnight Deliveries ( ONLY ):
West Virginia State Tax Department
West Virginia State Tax Department
IAD / Withholding
Revenue Center / Withholding
PO Box 3943
1001 Lee Street
Charleston WV 25339-3943
Charleston WV 25301-1725

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