SCHEDULE 
                         APPLICATION FOR DOWNSTREAM NATURAL GAS                                                        West Virginia 
  DNG-A                                                                                                                State Tax Department
  REV10-2020                 MANUFACTURING INVESTMENT TAX CREDIT
                                            FOR INVESTMENTS PLACED IN SERVICE ON OR AFTER JULY 1, 2020
A SEPARATE DNG-A MUST BE FILED FOR EACH YEAR IN WHICH INVESTMENT FOR PURPOSE OF THE DOWNSTREAM NATURAL GAS MANUFACTURING INVESTMENT TAX CREDIT 
  IS PLACED IN SERVICE OR USE. ADDITIONALLY, THE APPLICATION MUST BE APPROVED BY THE STATE TAX DEPARTMENT BEFORE ANY CREDIT MAY BE CLAIMED.
                                        SECTION A: BUSINESS IDENTIFICATION 
1 FEIN OR                               WV TAX ID                                   PREPARER’S EIN 
  SSN
                                                                TAX PERIOD
2 BEGINNING                                                                 ENDING
                MM           DD                   YYYY                                       MM       DD                  YYYY
  BUSINESS NAME
3
  ADDRESS

4 CITY                                                                              STATE                  ZIP

                    SECTION B: CREDIT CALCULATION AND QUALIFIED INVESTMENT
APPLICATION IS HEREBY MADE TO THE TAX COMMISSIONER OF WEST VIRGINIA FOR ALLOWANCE OF DOWNSTREAM NATURAL GAS MANUFACTURING INVESTMENT TAX 
CREDIT WITH RESPECT TO QUALIFIED INVESTMENT PROPERTY PLACED IN SERVICE OR USE DURING APPLICANT’S TAX YEAR, AS INDICATED ABOVE, AND THE NEW JOBS 
CREATED BY THE APPLICANT THAT ARE DIRECTLY ATTRIBUTABLE TO THE QUALIFIED INVESTMENT PROPERTY.
1 BUSINESS ACTIVITY IN WEST VIRGINIA  (THIS CREDIT IS ONLY AVAILABLE TO QUALIFIED DOWNSTREAM NATURAL GAS MANUFACTURERS)
  A) NORTH AMERICAN INDUSTRY CLASSIFICATION SYSTEM CODE (NAICS)
  B) NARRATIVE DESCRIPTION OF BUSINESS ACTIVITY IN WEST VIRGINIA

2                            INVESTMENT YEAR       TOTAL INVESTMENT                                   QUALIFIED INVESTMENT
                                             $$
  LOCATION(S) OF INVESTMENT IN WEST VIRGINIA
  GENERAL DESCRIPTION OF QUALIFIED INVESTMENT

3 PAYROLL AND EMPLOYMENT                          PAYROLL                                             JOBS 
  A. TOTAL PAYROLL  AND NUMBER OF JOBS
     PRIOR TO INVESTMENT                     $
  B. TOTAL PAYROLL  AND NUMBER OF JOBS
     THIS TAX YEAR                           $
  C.  PROJECTED WV PAYROLL AND NUMBER OF JOBS
     AFTER 3 YEARS                           $
  D.  MEDIAN COMPENSATION OF NEW JOBS        $
4 BENEFITS                   PERCENTAGE OF        AVERAGE ANNUAL COST PER EMPLOYEE                    NUMBER OF NEW JOBS WITH THE BENEFIT
                             EMPLOYEES COVERED
  A. HEALTH                                  %
  B. RETIREMENT                              %
  C. OTHER BENEFITS                          %
7 DOES THE TAXPAYER ELECT TO BEGIN THE 10-YEAR CREDIT PERIOD WITH THE NEXT SUCCEEDING TAXABLE YEAR?   YES                 NO
                                                                SIGNATURE
Under penalty of perjury, I declare that I have examined this return, accompanying schedules, and statements, and to the best of my knowledge and belief, it is true, correct and complete.

            SIGNATURE OF TAXPAYER                 NAME OF TAXPAYER (PRINT OR TYPE)                        TITLE           DATE

  SIGNATURE OF PREPARPER OTHER THAN TAXPATER                                      ADDRESS                                 DATE

                    PERSON TO CONTACT CONCERNING THIS RETURN                                               DAYTIME TELEPHONE
  DO NOT ATTACH THE APPLICATION TO YOUR ANNUAL RETURN.  RETURN THE COMPLETED APPLICATION TO 
  THE WEST VIRGINIA STATE TAX DEPARTMENT
  PO BOX 1202
  CHARLESTON WV 25324-1202.  
  IF YOU HAVE ANY QUESTIONS OR NEED FURTHER INFORMATION REGARDING THIS APPLICATION, 
  TELEPHONE (304) 558-3333, OR TOLL FREE TO 1-800-WVA-TAXS (1-800-982-8297).
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