BUS-REF                  APPLICATION FOR REFUND OF BUSINESS 
     REV02-19                                                 LICENSE REGISTRATION FEE 
                                                                   (WEST VIRGINIA CODE 11-12)
NAME OF BUSINESS                                                                             WEST VIRGINIA IDENTIFICATION NUMBER

ADDRESS

CITY                                                                                                                          STATE       ZIP

1 PERIOD FOR WHICH REFUND IS REQUESTED (Note: The Business License Registration Period covers fi scal year: JULY 1 - JUNE 30) 1

2 GROSS INCOME OF BUSINESS FOR THE LICENSE PERIOD THAT REFUND IS BEING REQUESTED                                             2

3 REFUND REQUESTED                                                                                                           3
4 REASON FOR REQUESTING REFUND

CAUTION: Read this application before signing.  Presenting a fraudulent claim constitutes a felony
I certify all information hereon to be true and accurate to the best of my knowledge.
                                                                                                                             Corporate Seal, if applicable

  SIGNATURE                                                   DATE

  PRINT NAME                                                  TITLE
       TAKEN, SUBSCRIBED, ACKNOWLEDGED AND 
       SWORN TO BEFORE ME ON THIS DATE :
                 MY COMMISSION EXPIRES ON:

                              NOTARY PUBLIC                                                                                  (NOTARY SEAL)

     MAIL TO:   WEST VIRGINIA STATE TAX DEPARTMENT
                TAX ACCOUNT ADMINISTRATION DIVISION
                REGISTRATION & ACCOUNT CORRECTION UNIT
                P. O. BOX 2666
                CHARLESTON, WV 25330-2666
     FOR ASSISTANCE CALL (304) 558-3333 TOLL FREE (800) 982-8297
     For more information visit our web site at: www.wvtax.gov