West Virginia 
                                               ApplicAtioN foR cERtificAtE of
WV/NRAE                                                                                                                                                       State Tax 
Rev. 05/14                                                   full oR pARtiAl ExEmptioN                                                                        Department
              Mail completed form to: WV State Tax Department, TAAD/Withholding, PO Box 784, Charleston, WV 25323-0784
                     Tax Year                                             Tax Year 
                     Beginning          MM     DD                YYYY            Ending     MM                 DD    YYYY
This form is to be used only to request a Certificate of Full or Partial Exemption from the withholding requirements on the proceeds of the sale or 
exchange of real property and associated tangible personal property in West Virginia by nonresident individuals and nonresident entities. This form 
must be rECEiVEd  by the WV State Tax department, Tax Account Administration division no later than 21 days before the closing date.
              For multiple tranFeror/sellers complete a separate Form WV/nrae for each one receiving proceeds.
                                           tRANsfERoR/sEllERs iNfoRmAtioN
Name (If joint, give first names and initials of both)       LaST Name (Give spouse’s last name, if different)    YouR SociaL SecuRiTY NumbeR

Name (Corporation, Partnership, Trust, Estate, etc.)
                                                                                                                  SPouSE’S SoCiAl SECuriTy numbEr
coRpoRaTe officeR, paRTNeR TRuSTee, execuToR oR aDmiNiSTRaToR
                                                                                                                     FEdErAl EmPloyEr id numbEr
aDDReSS (Number and street)

ciTY, STaTe aND zip coDe (province, postal code and country)
                                                                                                                          Ownership Percentage
Transferor/Seller’s Entity Type
   Individual                             corporation              S corporation     Partnership                       Limited Liability Company

   Limited Liability Partnership          business Trust           estate            Trust                             Other _____________________

                                                             pRopERty iNfoRmAtioN
DeScRipTioN of pRopeRTY (Include address, or county, district, partial or sub-partial if no    DaTe of cLoSiNg
address is available)
                                                                                                               MM    DD        YYYY
                                                                                               coNTRacT SaLeS pRice
                                                                                                                                          ●
                                                                                               pRopeRTY accouNT iD NumbeR

Transferor/Seller acquired property by:                                            transferor/seller’s Adjusted Basis:
   Purchase            1031 Exchange         Foreclosure/Repossession                                                                              ●
                                                                                   Purchase price..................
   gift                Inheritance           Other _________________________       Add: capital improvements 
                                                                                        and settlement costs                                       ●
Use of property at time of sale:                                                   Less: depreciation (if any)                                     ●
   Rental/             Secondary/            Vacant 
 Commercial            Vacation            Land                Other _____________ Adjusted basis...................                               ●

                                           tRANsfEREE/BuyER’s iNfoRmAtioN
NAME (If joint, give first names and initials of both)                                                       LAST NAME (Give spouse’s last name, if different)

coRpoRaTe officeR, paRTNeR, TRuSTee, execuToR oR aDmiNiSTRaToR

aDDReSS (Number and Street)

ciTY, STaTe aND zip coDe (province, postal code and country)

Transferee/Buyer’s Entity Type
   individual                      Partnership                              Business Trust                                Trust
   Corporation                     limited liability Company                Estate
   S Corporation                   limited liability Partnership            other _______________________

WV/NRAE       Application for Certificate of Full or Partial Exemption                                                                                      page 2
TrAnSFEror/                                                                               your SoCiAl SECuriTy 
SEllEr’S nAmE                                                                             numbEr/FEin

REAsoN foR full oR pARtiAl ExEmptioN fRom WithholdiNg (attach documentation and calculation)
Reason for exemption (check box if applicable and provide amount of total payment subject to tax).           Amount of total payment subject to tax
  1. Transfer is to a corporation controlled by a transferor.........................                     1                                                ●
  2. Transfer is pursuant to a tax-free organization...................................                   2                                                ●
  3. Transfer is pursuant to an installment sale and the transferor/seller 
     will receive less than the full purchase price during the taxable year                               3                                                ●
  4. Transfer is by a tax-exempt entity and transfer involves limited or no 
     unrelated business taxable income.....................................................               4                                                ●
  5. Transfer is by transferor to a partnership, such that no gain or loss is 
     recognized on the transfer...................................................................        5                                                ●
  6. Transfer is treated as a transfer by a partnership................................                   6                                                ●
  7. Transfer is treated as a transfer by a real estate investment trust.......                           7                                                ●
  8. Transfer is a tax-free exchange............................................................          8                                                ●
  9. Transfer is pursuant to a condemnation and conversion into similar property.............             9                                                ●
  10. Transfer is between spouses or incident to divorce...........................                       10                                               ●
  11. Transfer is treated as a transfer by an S corporation.........................                      11                                               ●
  12. Transfer is by transferor to a disregarded entity that is solely owned 
     by the transferor.................................................................................   12                                               ●
  13. Transfer is otherwise fully or partially exempt from the recognition 
     of gain in accordance with the attached explanation.........................                         13                                               ●

              pRoVidE BRiEf ExplANAtioN of youR REAsoN foR REquEstiNg ExEmptioN

                                          cAlculAtioN of tAx to BE WithhEld
1. Enter amount subject to tax........................................................................    1                                                ●

2. Enter tax rate, whichever applies:                         A) 2.5% of total payments or
                                                              B) 6.5% of estimated capital gains......... 2
3.  Amount of tax to withheld at closing. Line 1 multiplied by line 2. (This 
line must be completed).............................................................................      3                                                ●
Under penalties of perjury, I declare that I have examined this application and to the best of my knowledge and belief it is 
true and complete. If prepared by a person other than the transferor/seller, the declaration is based on all information of 
which the preparer has any knowledge.

Signature and title (if applicable)                         Date Signature of Spouse (if applicable)         Date Telephone number

Signature of preparer other than taxpayer                   Date Address and telephone number of preparer         preparer’s SSN or pTiN

                                            WV/NRAE 
INSTRUCTIONS FOR APPLICATION FOR CERTIFICATE FOR FULL OR PARTIAL EXEMPTION

         GENERAL INSTRUCTIONS                                          costs such as commissions and state transfer taxes), and subtracting 
                                                                       depreciation, if applicable.
         Purpose of Form
Use this form to apply for a Certificate of Full or Partial Exemption         Transferee/Buyer’s information
from the withholding requirements on the proceeds of the sale  Enter name and address.
of  real  and  associated  tangible  personal  property  in  WV  by 
                                                                       Check box indicating the transferee/buyer’s entity type.
nonresident individuals and nonresident entities. A nonresident 
entity is defined to mean an entity that:                              Attach schedule if there are multiple transferees/buyers.
(1) is not formed under the laws of WV; and                            Reason for Full or Partial Exemption from 
(2) is  not  qualified by  or  registered  with  the  WV  State  Tax          Withholding
Department to do business in WV.                                       Check applicable box(es) in the “Reason for Exemption” column 
         Who may file an application                                   that reflect the reason(s) for request of a full or partial exemption 
An individual, fiduciary, corporation, S corporation, limited          from the income tax withholding requirement.
liability company, or partnership transferor/seller may file Form  Indicate the amount that you are claiming as subject to tax and 
WV/NRAE. A separate Form WV/NRAE is required for each  upon which the income tax withholding should be calculated in 
transferor/seller unless the transferor/seller are a husband and wife  the “Amount of Total Payment Subject to Tax” column.
filing a joint WV Income Tax return.
                                                                       Specific line instructions for Reason for Full or 
IMPORTANT: The completed Form WV/NRAE must be 
                                                                              Partial Exemption
received by the WV State Tax Department no later than 21 days 
                                                                       LINE 1 Transfer is to a corporation controlled by the transferor.
before the closing date of the sale or transfer to ensure timely 
receipt of the Certificate of Full or Partial Exemption.               Required documentation: Copy of the agreement of sale; Certificate 
                                                                       of Good standing of transferee issued by the state in which 
         SPECIFIC INSTRUCTIONS                                         transferee is incorporated; notarized affidavit executed on behalf of 
Enter tax year of the transferor/seller if other than a calendar year. transferee by its President and Treasurer stating that immediately 
                                                                       after the exchange the transferor(s) will own stock in the transferee 
         Transferor/Seller’s information
                                                                       possessing at least eighty percent (80%) of the total combined 
Enter name, address and indentification number (social secuity 
                                                                       voting power of all classes of transferee’s stock entitled to vote and 
or federal employer identification number) of the transferor/seller 
                                                                       at least eighty percent (80%) of the total number of shares of all 
applying for the exemption. If the transferor/seller was issued an 
                                                                       other classes of stock of the transfer; and an appraisal establishing 
individual taxpayer identification number (ITIN) by the IRS, enter 
                                                                       the fair market value, at the time of exchange, of any property other 
the ITIN.
                                                                       than stock in the transferee which is part of the consideration for 
Check the box indicating the transferor/seller’s entity type.          the exchange. Fair market value of any such other property and/
Enter transferor/seller’s ownership percentage of the property.        or any money which is part of the consideration for the exchange 
                                                                       must be stated on the application as the taxable amount.
         Property information
Enter description of the property, including street address(es) as     LINE 2 Transfer is pursuant to a tax-free reorganization.
listed  with  the  WV State Tax Department.  If  the  property  does  Required documentation: Copy of agreement governing transfer 
not have a street address, provide the full property account ID  between transferor and transferee; Certificates of Good Standing 
number used by the County Assessor to identify the property (legal  of transferor and transferee issued by the state(s) in which 
description and I. D. number)                                          transferor and  transferee are  incorporated;  copy of the plan of 
Enter date of closing for the sale or transfer of the property.        reorganization showing that transferor and transferee are parties 
                                                                       to the reorganization, and an appraisal establishing fair market 
Enter contract sales price of the property being sold or transferred.  value, at the time of the exchange, of any property other than stock 
Enter property account ID number. If the property is made up of  or  securites  in  the  transferee  which  is  part  of  the  consideration 
more than one parcel and has more than one property tax account  for the exchange and will not be distributed by the transferor in 
number, include all applicable property account ID numbers.            pursuance of the plan of reorganization. The fair market value of 
                                                                       any such other property and/or any money which is part of the 
Check box describing the transferor/seller’s acquisition of the 
                                                                       consideration for the exchange and will not be distributed by the 
property.
                                                                       transferor in pursuance of the plan of reorganization must be stated 
Check box describing the transferor/seller’s use of the property  on the application as the taxable amount.
at the time of the current sale, and enter the length of time the 
                                                                       LINE 3 Transfer is pursuant to an installment sale.
property has been used for this purpose.
                                                                       Required documentation: Copy of contract of sale or copy of 
Complete the transferor/seller’s Adjusted Basis section by entering 
                                                                       HUD-1 settlement sheet; copy of promissory note to transferor 
the purchase price when the transferor/seller acquired the property, 
                                                                       which will be executed by transferee at settlement. That portion 
adding the cost of capital improvements (including acquisitions 
                                                                       of the total payment that the transferor receives at or within sixty 

(60) days of settlement must be stated on the application as the  purposes of §1041 of the Internal Revenue Code.
taxable amount.                                                        Required documentation: Copy of marriage license or divorce 
LINE 4 Transfer is by a tax-exempt entity for purposes of §501(a)  decree; copy of deed which will be recorded to accomplish the 
of the Internal Revenue Code and transfer involves limited  transfer; if incident to divorce, copy of section of court order or 
or  no  unrelated  business  taxable  income  under  §512  of  the  separation agreement governing transfer of the property.
Internal Revenue Code.                                                 LINE 11 Transfer is treated as a transfer by an S corporation for 
Required documentation: Copy of determination by the Internal  purposes of §1368 of the Internal Revenue Code.
Revenue Service that transferor is a tax-exempt entity for purposes    Required documentation: Copy of agreement governing transfer 
of §501(a) of the Internal Revenue Code; Certificate of Good           between transferor and transferee; copy of approval by the Internal 
Standing of transferor issued by the state in which transferor         Revenue Service of transferor’s S corporation election; Certificate 
is incorporated; notarized affidavit executed on behalf of             of Good Standing issued by the state in which transferor is 
transferor by its President and Treasurer stating that the transfer    incorporated.
involves limited or no unrelated business income under §512 of 
the Internal Revenue Code.                                             LINE 12 Transfer is to a disregarded entity, classified as such, that 
                                                                       is solely owned by the transferor.
LINE 5 Transfer is to a partnership in exchange for an interest in 
the partnership such that no gain or loss is recognized under §721     Required documentation: Copy of agreement governing transfer 
of the Internal Revenue Code.                                          from transferor to transferee; certified copy of transferee’s Articles 
                                                                       of Organization; Certificate of Good Standing of transferee issued 
Required documentation: Copy of agreement governing transfer           by the state in which transferee is organized; copy of transferee’s 
between transferor and transferee; copy of the partnership             Operating Agreement.
agreement of the transferee.
                                                                       LINE 13 Transfer is otherwise fully or partially exempt from the 
LINE 6 Transfer is by a partnership to a partner of the partnership    recognition of gain in accordance with attached explanation.
in accordance with §721 of the Internal Revenue Code.
                                                                       Required documentation: Attach any and all documents necessary 
Required documentation: Copy of agreement governing transfer           to show that the transfer is fully or partially exempt from tax.
between transferor and transferee; copy of the partnership 
agreement of the transferor.                                           Provide brief explanation of your reason for 
LINE 7 Transfer is treated as a transfer by a real estate investment                 requesting exemption
trust for purposes of §857 of the Internal Revenue Code.               Provide a brief explanation of why the sale or transfer of the 
                                                                       property qualifies for a full or partial exemption from the income 
Required documentation: Copy of agreement governing transfer           tax withholding requirement. If necessary, attach additional 
between transferor and transferee; certified copy of Articles of       documentation to support your request for a full or partial 
Incorporation of transferor; Certificate of Good Standing of           exemption, and to support your calculation of the dollar amount 
transferor issued by the state in which transferor is incorporated.    subject to tax, if the request is for partial exemption.
LINE 8 Transfer is a tax-free exchange for purposes of §1031 of the           Calculation of tax to be withheld
Internal Revenue Code.                                                 Complete this section if you are requesting a partial exemption. 
Required documentation:  Letter  signed by  the qualified  This section must be completed or the application for partial 
intermediary, or by the person authorized to sign on behalf of a  exemption will be denied.
business entity acting as the qualified intermediary, which states                           Signature(s)
the name(s) of the transferor(s), property description, that the  Form WV/NRAE must be signed by an individual (both taxpayer 
individual or business will be acting as the qualified intermediary  and spouse if filing a joint WV income tax return), or a responsible 
for the transferor(s) as part of a 1031 exchange of the property,  corporate officer.
whether there will be any boot, and if so, the amount of boot. 
                                                                       Please include a daytime telephone number where you can be 
The amount of any  boot must  be stated on the application as 
                                                                       reached between 8:00 AM and 5:00PM EST.
the taxable amount.
                                                                       Your signature(s) signifies that your application, including all 
LINE 9  Transfer is pursuant to a condemnation and 
                                                                       attachments is, to the best of your knowledge and belief, true, 
conversion into a similar property for purposes of §1033 of the 
                                                                       correct and complete, under the penalties of perjury.
Internal Revenue Code.
                                                                       If a power of attorney is necessary, complete federal Form 2848 and 
Required documentation: Copy of agreement governing transfer 
                                                                       attach to your application.
between transferor and government body or authority condeming 
the property; notarized affidavit executed by transferor stating                             Where to file
that transferor will identify and purchase replacement property        Mail the completed form and all attachments to:
within the time limits required by §1033 of the Internal Revenue       West Virginia State Tax Department
Code, or copy of contract of sale if transferor has already identified Tax Account Administration Division/Withholding Unit
replacement property. If proceeds  from condemnation exceed            PO BOX 784
price of replacement property, the excess must be stated on the        Charleston WV 25323-0784
application as the taxable amount.                                     Additional information
                                                                       For additional information, please call 1-800-982-8297 or 
LINE 10 Transfer is between spouses or incident to divorce for         (304) 558-3333 or TDD (hearing impaired) 1-800-282-9833.