STATE OF WEST VIRGINIA 
                State Tax Department, Tax Account Administration Div
                P. O. Box 1667
                Charleston, WV 25326-1667

                Name

                Address                                                                                         Account #:

                City                                                            State                 Zip

WV-945              WEST VIRGINIA QUARTERLY RETURN OF BACKUP WITHHOLDING
rtL052  v 2-Web                                              OF GAMBLING WINNINGS

Tax Period                                                                                                                              Check here if this is
                                                             Due Date
Ending                                                                                                                                  an amended return

1. Total gambling awards paid out this quarter .......................................................................                1
                                                                                                                                                               .
                                                                                                                                      2
2. Total backup withholding due this quarter                 ........................................................................                          .
                                                                                                                                      3
3. Total backup withholding payments made for this quarter .................................................                                                   .

4. Balance due (If line 2 is greater than line 3, enter the difference) ......................................                        4                        .
5. Overpayment (If line 3 is greater than line 2, enter the difference)                                  ...... Refund ......         5                        .

    6.  Quarterly Summary of State Tax Liability (write the names of the months on the lines provided)
                                                                                                                                        Tax liability for month
A.  Month 1:  _______________________________ ............................................................                            A
                                                                                                                                                               .
B.  Month 2:  _______________________________                                                                                         B
                                                                  ............................................................                                 .

C.  Month 3:  _______________________________                                                                                         C
                                                                  ............................................................                                 .

D.  Total liability for the quarter (add lines A through C) ......................................................                    D
                                                                                                                                                               .

                Under penalties 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.

Sign            (Signature of Taxpayer)                           (Print Your Name and Title)                                           (Date)
Your
Return          (Person to Contact Concerning this Return)                                                      (Telephone Number)

                (Signature of Preparer other than Taxpayer)       (Address)                                                             (Date)

                MAIL TO:  WEST VIRGINIA STATE TAX DEPARTMENT
                        Tax Account Administration Div
                        P. O. Box 1667, Charleston, WV  25326-1667
                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                                                B     7     2     2     0     1     1     0     1     W