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-02 rtL166 v 6 Web DIRECT SHIPPER'S REPORT OF WINE SHIPPED INTO WEST VIRGINIA 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. Total Liters (Sum all total invoices) From Page 2 Schedule A 2. Tax Rate 3. Total State Excise Tax (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 5 4 0 2 0 9 0 1 W American LegalNet, Inc. www.FormsWorkFlow.com WV/WNE-02 rtL166 v 6 Web DIRECT SHIPPER'S REPORT OF WINE SHIPPED INTO WEST VIRGINIA Schedule A (Liters = Gallons x 3.7854) Invoice Date MMDDYYYY Invoice Number Customer Name City WV/ABCA Permitted Carrier Making Delivery Total Invoice Wine Liters Total Liters (Sum all total invoices) Enter here and on Page 1 Line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2