Form Wv/hcp-3a - Annual Return Of Broad Based Health Care Related Taxes
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1
2STATE OF WEST VIRGINIA
State Tax Department, Tax Account Administration Div
P.O. Box 773
Charleston, WV 25323-0773
Name
Address
Account #:
City
State
Zip
ANNUAL RETURN OF BROAD BASED HEALTH CARE RELATED TAXES
WV/HCP-3A
rtL301 v 4-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.
Period Ending:
Due Date:
Extension Date:
M
M
D
D
Y
Y
Y
Y
Method of Accounting
ACCRUAL
CASH
FINAL
AMENDED
(Check One)
COMPUTATION OF TAX
1.
Total Annual Tax Due from Schedule A Line 7
.
2.
Total Estimated Payments for the Period Covered by this Return
.
3.
Credit for Overpayment from Prior Year Annual Return
.
4.
Total Payments and Credits (Add Lines 2 and 3)
.
5.
Total Tax Due (Line 1 minus Line 4 - If Line 4 is Greater than Line 1, Enter 0)
.
6. Overpayment Amount (Line 4 minus Line 1 - If Line 1 is Greater than Line 4, Enter 0)
.
7. Amount of Line 6 to be Credited to Next Year's Tax
.
8. Amount of Line 6 to be Refunded (Line 6 minus Line 7)
.
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)
(Signature of preparer other than taxpayer)
(Address)
(Date)
MAIL TO: WEST VIRGINIA STATE TAX DEPARTMENT
Tax Account Administration Div
P.O. Box 773, Charleston, WV 25323-0773
FOR ASSISTANCE CALL (304) 558-3333 TOLL FREE (800) 982-8297
For more information visit our web site at:
H
0
4
0
7
1
0
0
1
W
File online at https://mytaxes.wvtax.gov
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