PCM-A                      APPLICATION FOR POST-COAL MINE                                                               West Virginia 
                                                                                                                      State Tax Department
   REV06-2020                                   SITE BUSINESS CREDIT
                                                (FOR PERIODS ON OR AFTER JANUARY 1, 2020)
AN APPLICATION MUST BE FILED FOR EACH YEAR IN WHICH INVESTMENT FOR PURPOSES OF THE POST-COAL MINE SITE BUSINESS CREDIT IS PLACED IN SERVICE OR USE.
                                            SECTION A: BUSINESS IDENTIFICATION 
 1 BUSINESS                                                                  WV TAX ID                          ENTITY 
   NAME                                                                                                         TYPE
 2 TAXPAYER                                                                  TAXPAYER
   FIRST NAME                                                                LAST NAME
                                                              TAX PERIOD
 3 BEGINNING                                                                 ENDING
                   MM         DD                      YYYY                               MM               DD               YYYY
   ADDRESS

 4
   CITY                                                                                 STATE                   ZIP

   APPLICATION IS HEREBY MADE TO THE TAX COMMISSIONER OF WEST VIRGINIA FOR ALLOWANCE OF 
5  POST-COAL MINE SITE BUSINESS CREDIT WITH RESPECT TO QUALIFIED CAPITAL EXPENDITURES 
   PLACED IN SERVICE OR USE DURING THE APPLICANT’S TAX YEAR ENDING :                     MM               DD               YYYY
   HAS  THE  ABOVE NAMED BUSINESS ENTITY BENEFITED FROM OTHER STATE ECONOMIC 
6  DEVELOPMENT PROGRAMS OR INCENTIVES THAT RESULTED IN A REDUCTION OF THEIR INCOME       YES, IF YES, THE BUSINESS IS NOT      NO
   TAX LIABILITY?                                                                        ELIGIBLE FOR THIS CREDIT.  
                      SECTION B: PRINCIPAL BUSINESS LOCATION IN WEST VIRGINIA 
   ADDRESS OF PRINCIPAL BUSINESS LOCATION IN WEST VIRGINIA

7
   CITY                                                                                                   STATE            ZIP

   DATE OF INITIAL LOCATION OF PRINCIPAL PLACE OF                                             DATE MINING 
8  BUSINESS AT SITE (CREDIT CAN ONLY BE EARNED DURING                                         ACTIVITY AT 
   THE FIRST FIVE YEARS AFTER INITIAL LOCATION)       MM      DD             YYYY             SITE CEASED MM        DD                   YYYY
   NAME OF FORMER MINE SITE                                                                                         LAST ISSUES COAL PERMIT #
9

   ADDRESS OF PHYSICAL LOCATION OF MINE SITE

10
   CITY                                                                                                   STATE            ZIP

   DESCRIBE ANY USE OF SITE AFTER MINING ACTIVITY CEASED
11

12 INVESTMENT                 AMOUNT                                                          NUMBER OF FULL-TIME EMPLOYEES
   YEAR
   GENERAL DESCRIPTION OF QUALIFIED INVESTMENT 
13

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                                                      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).