Form Wv/cst-250 - Application/renewal-Direct Pay Permit

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WV/CST-250 (Rev. 9/89)

West Virginia

Department of

Tax and Revenue

WEST VIRGINIA

CONSUMERS SALES AND USE TAX

A P P L I C A T I O N / R E N E W A L - D I R E C T

P A Y

P E R M I T

Enter your West Virginia

Identification Number

Business Name

Owner's Name

Street Address

City, State & Zip

This business

does

does not (check one) currently hold a direct pay permit

COMPLETED

OWNER,

PARTNER

OFFICER

CORPORATION

, the undersigned, hereby certify that:

- The above business has a valid Business Registration Certificate #

and this certificate has not

been suspended or revoked; and

- The above business is not delinquent on the payment of any taxes imposed by Chapter 11 of the West Virginia Code; and

- This business satisfies one or more of the following conditions (check all applicable boxes):

Engaged in the business of manufacturing;

Subject to Telecommunications tax under W. Va. Code Section

11-13B-1 et seq.;

Subject to Severance tax under W. Va. Code Section 11-13A-1

et seq.;

A bona fide charitable organization that makes no charge whatso-

ever for service rendered;

Engaged in the business of producing natural resources;

A volunteer fire department organized and incorporated under the

laws of West Virginia;

Engaged in the business of transportation;

A nationally chartered fraternal or social organization;

Engaged in the business of communication;

Engaged in the business of transmission;

Subject to the [State] Business & Occupation tax under W. Va.

Code Section 11-13-1 et. seq.;

Makes purchases of tangible personal property or services, the use of which is unknown to me at the time of the purchase and one of the reasonably

foreseeable uses would render the purchase exempt from sales and use taxes.

Explain generally the types of purchases:

On behalf of the above business, I am hereby applying for a direct pay permit.

Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, accurate and complete.

Signature of Applicant

D a t e

Name of Applicant (Please Print)

Title

Telephone Number

(Owner; Partner; Officer of Corporation)