Schedule         WITHHOLDING FOR BENEFICIARIES AND 
      SB
    Form IT-141      NON-RESIDENT TAX PAID FOR WITHHOLDING 
                                                                                      2022
                ATTACH ADDITIONAL COPIES OF WITHHOLDING FOR BENEFICIARIES AS NEEDED
                       NAME AND ADDRESS OF EACH BENEFICIARY
                NAME         STREET OR MAILING ADDRESS           CITY                 STATE ZIP CODE
1  

2  

3  

4  

5  

6  

7  

8  

9  

10  
        (A)                                             (E)      (F)                  (G)   (H)
                                                                 BENEFICIARY SHARE OF RATE  TAX PAID FOR 
SOCIAL SECURITY       WEST VIRGINIA FILING METHOD     IF NRW-4 WV INCOME                  BENEFICIARIES 
        #       (B) RESIDENT (C) COMPOSITE (D) NONRES PREVIOUSLY                            WITHHOLDING
                                                      FILED
1                                                                                     6.5%

2                                                                                     6.5%

3                                                                                     6.5%

4                                                                                     6.5%

5                                                                                     6.5%

6                                                                                     6.5%

7                                                                                     6.5%

8                                                                                     6.5%

9                                                                                     6.5%

10                                                                                    6.5%

TOTALS                                                                                6.5%

                                                                 *P35202202W*
                                                                 P35202202W
                                                   2