Form Wv/nrw-4 - West Virginia Nonresident Income Tax Agreement

ADVERTISEMENT

WV/NRW-4
West Virginia Nonresident Income Tax Agreement
B
REV 08-10
Read Instructions on Reverse Side
Part I:
ORGANIZATION NAME AND MAILING ADDRESS
NONRESIDENT NAME AND MAILING ADDRESS
Name (please type or print)
Name (please type or print)
Post Office or Street Address
Post Office or Street Address
City/Town
State
Zip Code
City/Town
State
Zip Code
Social Security Number
West Virginia Identification Number
Federal Identification Number
Spouse's Social Security Number
or Federal Identification Number
Type of Nonresident:
Type of Organization: (check only one)
Individual
Corporation
Partnership
Partnership
S Corporation
Estate
Trust
Limited Liability Company
Nonresident's Taxable Year:
Taxable Year of Organization:
Calendar Year
Calendar Year
Fiscal Year Ending
Fiscal Year Ending
State of Residence or Commercial Domicile:
State of Commercial Domicile:
Internal Revenue Service Center Where Organization's Federal Return
Internal Revenue Service Center Where Nonresident's Federal Return
is Filed:
Is Filed:
City
State
City
State
Part II:
I declare that the above-named Distributee is a nonresident of West Virginia and that the nonresident Distributee hereby agrees to timely file West
Virginia Income Tax Returns (Form IT-140 or WV/CNF-120) and pay any income tax due; that the Distributee will include in that return the portion of the
above-named Organization’s West Virginia income or gain attributable to the nonresident Distributee’s interest in such Organization for the taxable year
of the Distributee during which this Form is filed with the Organization and for each succeeding taxable year for which the Distributee receives actual
or deemed distributions of West Virginia source income or gain; and that this Agreement remains in effect until it is revoked by either the Distributee or
the Tax Commissioner.
SIGN
HERE
(Signature of Nonresident Partner, Shareholder, or Beneficiary, or of Authorized Corporate Officer)
(Print Name Signed Above)
(Mailing Address if Different from Above)
(Date)
Part III:
NOTICE OF REVOCATION OF NONRESIDENT INCOME TAX AGREEMENT
WARNING: COMPLETE ONLY IF REVOKING AGREEMENT
Notice is hereby given that the West Virginia Nonresident Income Tax Agreement (Form WV/NRW-4) previously executed by or on behalf of the above-
named Nonresident is revoked for taxable years of the above-named Organization (Pass-through entity) that begins after today's date.
SIGN
HERE
(Signature of Nonresident Partner, Shareholder, or Beneficiary, or of Authorized Corporate Officer)
(Print Name Signed Above)
(Mailing Address if Different from Above)
(Date)
-16-

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go
Page of 2