Form Wv/rafbrd-1 - License Application To Sell Raffle Boards And Games printable pdf download

STATE OF WEST VIRGINIA

State Tax Department, Charitable Bingo/Raffle Unit

P.O. Box 1143

Charleston, WV 25324-1143

Name

Address

Account #:

City

State

Zip

LICENSE APPLICATION TO SELL RAFFLE BOARDS AND GAMES

WV/RAFBRD-1

rtL181 v 11-web

Taxpayers required to file electronically will no longer receive returns for the tax types subject to the mandatory

requirement by mail. Please visit for additional information.

Registration Year:

Due Date:

Check Type:

Wholesaler or Distributor

Manufacturer

Manufacturer and Distributor

Under West Virginia Code § 47-23 Wholesalers, Distributors or Manufacturers making sales to West Virginia Retailers

must have a current Raffle Boards and Games License.

The annual fee is $500.00 - Amount Enclosed

Also you must be registered to do business in the State of West Virginia pursuant to the provisions of West Virginia Code § 11-12.

If you have not registered to do business in West Virginia, please review the information in the enclosed booklet, complete the

Application for Registration Certificate (WV/BRT-801) and mail it with this application.

IF YOU ARE A NONRESIDENT SUPPLIER OF RAFFLE BOARDS AND GAMES TO WEST VIRGINIA

RETAILERS, YOU MUST DESIGNATE A RESIDENT AGENT UPON WHOM NOTICE OF PROCESS

MAY BE SERVED. PLEASE FURNISH THE FOLLOWING INFORMATION:

RESIDENT AGENT:

TELEPHONE:

STREET:

CITY:

STATE:

ZIP CODE:

Complete and return this application and $500.00 remittance.

Make checks payable to West Virginia State Tax Department

Should you have any questions, please contact the Charitable Bingo/Raffle Unit at (304) 558-8510

Make a photocopy of this application for your records before mailing it.

Sign Your Return

Under penalties of perjury, I declare that I have examined this return (including accompanying schedules and statements) and to the

best of my knowledge and belief it is true and complete.

(Signature of Taxpayer)

(Name of Taxpayer - Type or Print)

(Title)

(Date)

(Person to Contact Concerning this Return)

(Telephone Number)

(E-mail Address)

(Signature of preparer other than taxpayer)

(Address)

(Date)

MAIL TO: WEST VIRGINIA STATE TAX DEPARTMENT

Charitable Bingo/Raffle Unit

P.O. Box 1143, Charleston, WV 25324-1143

FOR ASSISTANCE CALL (304) 558-8510

For more information visit our web site at:

File online at https://mytaxes.wvtax.gov

Form Wv/rafbrd-1 - License Application To Sell Raffle Boards And Games

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