Form It-141 - West Virginia Fiduciary Income Tax Return (For Resident And Non-Resident Estates And Trusts) - 2014 Page 2
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4estate or trust name:______________________________________
fein: _________________________________
SCheDule a – BenefiCiary information anD non-reSiDent tax PaiD for withholDing
ATTACh ADDITIoNAl CoPIES oF SChEDulE AS NEEDED
name anD aDDreSS of eaCh BenefiCiary
NAME
STREET oR oThER MAIlING ADDRESS
CITY
STATE
ZIP CoDE
1.
2.
3.
4.
5.
(A)
WEST VIRGINIA FIlING
(E)
(F)
(G)
(h)
METhoD
BENEFICIARY
TAx PAID FoR
IF NRW-4
SoCIAl
ShARE oF WV
BENEFICIARIES
PREVIouSlY
(B)
(C)
(D)
SECuRITY #
INCoME
RATE
WIThholDING
RESIDENT
CoMPoSITE
NoNRES
FIlED
1.
6.5%
2.
6.5%
3.
6.5%
4.
6.5%
5.
6.5%
6. ToTAlS
6.5%
SCheDule B – weSt Virginia fiDuCiary moDifiCationS
ColuMN I
ColuMN II
ToTAl
AMouNT AlloCATED
aDDitionS:
1.
Interest income on state and municipal bonds, other than West Virginia................................
2.
lump sum distribution (Federal Form 4972)..........................................................................
3.
Federal exemption (Form 1041, line 20).................................................................................
If this is
4.
other additions – state nature and source _____________________________ ....................
a Simple
Trust
5.
Electing small business trust additions....................................................................................
having
6.
Total additions (add lines 1 through 5, col. II and enter here and on page 1, line 2)..............
No
SuBtraCtionS:
Taxable
Income,
7.
Interest income on US obligations specifically exempt from state tax...................................
oMIT
8.
West Virginia exemption..........................................................................................................
600.00
600.00
Col. II
9.
other subtractions – state nature and source __________________________ .....................
10. Electing small business trusts subtractions..............................................................................
11. Total subtractions (add lines 7 through 10, col. II and enter here and on page 1, line 3)........
12. Net fiduciary modifications (line 6 minus line 11)..................................................................
Direct
Deposit
ChECkING
SAVINGS
of refund
RouTING NuMBER
ACCouNT NuMBER
PleaSe reView your aCCount information for aCCuraCy. ProViDing inCorreCt aCCount information may reSult in
a $15.00 return Payment Charge.
Under penalties of perjury, I declare that I have examined this return, accompanying schedules and statements, and to the best of my knowledge and
belief it is true, correct, and complete. I authorize the State Tax Department to discuss my return with my preparer.
YES
No
___________________________________________________________________________________________________________
(Signature of Fiduciary or Officer Representing Fiduciary)
(Date)
Paid
(Signature of Preparer)
(Date)
Preparer’s
use only
(Firm’s Name)
(Address & ZIP Code)
(Telephone Number)
*p35201402w*
-2-
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