STATE OF WEST VIRGINIA State Tax Department, Tax Account Administration Div P.O. Box 2991 Charleston, WV 25330-2991 Name Address City State Zip Account #: WV/WNE-01 rtL165 v 6 Web WEST VIRGINIA WINE SUPPLIER'S REPORT Taxpayers required to file electronically will no longer receive returns for the tax types subject to the mandatory requirement by mail. Please visit www.wvtax.gov for additional information. This report must be filed even if no activity has occurred **Prepare this report in duplicate and mail the original with invoices and payment of taxes to the WV State Tax Department. Mail a copy of return and invoices to Alcohol Beverage Control Administration, 902 Pennsylvania Ave 4th Fl, Charleston, WV 25304 on or before the 15th day of each month.** Period Ending: Due Date: FINAL AMENDED TAX CALCULATION 1. 2. 3. Total number of liters shipped into West Virginia (From Page 2 Total) Tax Rate Balance of Tax Due (Line 1 multiplied by Line 2) . 0.26406 . 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 Tax Account Administration Div P.O. Box 2991, Charleston, WV 25330-2991 FOR ASSISTANCE CALL (304) 558-3333 TOLL FREE (800) 982-8297 For more information visit our web site at: www.wvtax.gov File online at https://mytaxes.wvtax.gov O 3 2 0 2 0 9 0 1 W American LegalNet, Inc. www.FormsWorkFlow.com WV/WNE-01 rtL165V 6 Web WEST VIRGINIA WINE SUPPLIER'S REPORT SECTION 1 - WINE SHIPPED INTO WEST VIRGINIA Non-registered suppliers - Report on section 2, page 3 (Liters = Gallons x 3.7854) Wholesaler/Distributor Sold Or Delivered To Business Name 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Invoice Information (Column A) Invoice # (Column B) Invoice Date (MMDDYYYY) Wine Shipped into WV (Column C) # Liters Total number of liters shipped into West Virginia (Enter here and on Page 1 Line 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com WV/WNE-01 rtL165V 6 Web WEST VIRGINIA WINE SUPPLIER'S REPORT SECTION 2 - NON-REGISTERED SUPPLIER SHIPMENTS WV Suppliers - Report purchases below SUPPLIER LOCATION INVOICE DATE INVOICE NUMBER (Liters = Gallons x 3.7854) TOTAL LITERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com