Form # - West Virginia Tax Amnesty Application

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FORM #
WEST VIRGINIA TAX AMNESTY APPLICATION
AMNESTY PERIOD SEPTEMBER 1, 2004 THROUGH NOVEMBER 1, 2004
PLEASE READ INFORMATION AND INSTRUCTIONS CAREFULLY
West Virginia has established a one-time Tax Amnesty Program beginning on September 1, 2004 and ending on November 1, 2004. Civil and criminal penalties will be
waived for a taxpayer who applies for amnesty during the amnesty period and pays the full amount of tax and half of the accrued interest.
SECTION I: TYPE OR PRINT YOUR NAME MAILING ADDRESS AND TAX IDENTIFICATION NUMBER (
USE CURRENT INFORMATION).
PERSONAL INCOME TAX
BUSINESS TAX
TAXPAYER NAME
SOCIAL SECURITY NUMBER
TAX IDENTIFICATION NUMBER
-
-
-
-
-
SPOUSE’S NAME (IF JOINT RETURN)
SPOUSE’S SOCIAL SECURITY
BUSINESS NAME
DBA (IF DIFFERENT FROM BUSINESS NAME)
NUMBER
-
-
CURRENT MAILING ADDRESS (NUMBER, STREET, P.O. BOX)
CITY
STATE
ZIP
ARE YOU CURRENTLY IN BANKRUPTCY?
_____ YES _____ NO
HAVE YOU BEEN CONTACTED BY A COLLECTION AGENCY REGARDING YOUR STATE TAX LIABILITY?
_____ YES _____ NO
DO YOU CURRENTLY HAVE AN APPEAL BEFORE THE OFFICE OF TAX APPEALS OR CIRCUIT COURT?
_____ YES _____ NO
HAVE YOU BEEN AUDITED BY THE WEST VIRGINIA STATE TAX DEPARTMENT?
_____ YES _____ NO
ARE YOU CURRENTLY UNDER CRIMINAL INVESTIGATION BY A STATE AGENCY?
_____ YES _____ NO
SECTION II: PLEASE LIST ALL OUTSTANDING LIABILITIES AND TAX RETURNS (INCLUDING PERIODS NOT ELIGIBLE FOR AMNESTY)
A. EXISTING TAX LIABILITIES
B. RETURNS TO BE FILED AND/OR AMENDED
(USE ADDITIONAL SHEETS IF NEEDED)
(USE ADDITIONAL SHEETS IF NEEDED)
KIND OF TAX
PERIOD
PERIOD
TAX AMOUNT
INTEREST DUE
TOTAL AMOUNT
KIND OF TAX
PERIOD
PERIOD
TAX AMOUNT
INTEREST DUE
TOTAL AMOUNT
BEGINNING
ENDING
DUE
(50%)
DUE
BEGINNING
ENDING
DUE
(50%)
DUE
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
SECTION III: SIGN AND DATE APPLICATION
I CERTIFY THAT I AM ELIGIBLE FOR AMNESTY UNDER THE CONDITIONS AS PROVIDED IN CHAPTER 11, ARTICLE 10D AND THAT THE INFORMATION ON THIS APPLICATION IS TO THE BEST OF
MY KNOWLEDGE, TRUE, CORRECT AND COMPLETE AND TO THE BEST OF MY KNOWLEDGE I AM NOT UNDER CRIMINAL INVESTIGATION BY ANY STATE AGENCY.
SIGNATURE OF TAXPAYER
DATE
I authorize the State Tax Department to discuss my amnesty
application with:
SPOUSE’S SIGNATURE (IF JOINT INCOME TAX APPLICATION)
DATE
Name: __________________________________________
Telephone: _________________________________________
SIGNATURE AND TITLE OF AUTHORIZED AGENT
CURRENT MAILING ADDRESS (NUMBER, STREET, P.O. BOX), CITY, STATE, ZIP

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