STATE OF WEST VIRGINIA                                                                                                      ,<t_Pffs.ea;.%, 
        State Tax Department, Tax Account Administration Div
        P.O. Box 2666                                                                                                                               \ 
                                                                                                                                                    ;;:~ 
        Charleston, WV 25330-2666

        Name

        Address
                                                                                                         Account #:
        City                                                            State                 Zip

     BUS-FIN
        REV 05/19      DECLARATION OF FINAL BUSINESS ACTIVITY

                                                                                                               LAST DATE OF ACTIVE
                       FEIN                          BUSINESS REGISTRATION                                          BUSINESS IN WV
                  (SSN For Sole Proprietor)                       ACCOUNT #                                            MM/DD/YYYY

                                            SECTION A: DESCRIPTION OF CEASED ACTIVITY
  REASON FOR CLOSING ACCOUNT. Select one below
    o   1. YOUR BUSINESS ACTIVITY WAS ONLY IN WV FOR A LIMITED TIME OR SINGLE EVENT. YOU WANT TO CLOSE ALL TAX ACCOUNTS FOR YOUR BUSINESS.

    o    2. YOU CONSIDERED CONDUCTING BUSINESS ACTIVITY IN WV BUT NEVER ACTUALLY STARTED. YOU WANT TO CLOSE ALL TAX ACCOUNTS FOR YOUR BUSINESS.

     o    3. OTHER. DESCRIBE: ____________________________________________________________________________________________________________________________
                     _______________________________________________________________________________________________________________________________________________
 
                    _______________________________________________________________________________________________________________________________________________
 
                    _______________________________________________________________________________________________________________________________________________
                                                     SECTION B: DESCRIPTION OF BUYER
   IF YOU HAVE SOLD THE BUSINESS PLEASE PROVIDE THE FOLLOWING INFORMATION:
       ID NUMBER OF BUYER               NAME OF BUYER

                                     I 
   ADDRESS OF BUYER

  CITY                                                                                                     STATE                    ZIP
                                                                                                                                  I 

  EMAIL

                                                           SECTION C: SIGNATURE
  I CERTIFY THAT THE INFORMATION PROVIDED ON THIS FORM IS TRUE AND CORRECT.
SIGNATURE OF APPLICANT                                                                                             DATE

  PRINT NAME                                                                                       TITLE           SSN

  EMAIL

     atL099  v.18

                   Tax Account Administration Div       n  P.O. Box 2666        n                        Charleston, WV 25330-2666
                                                     (304) 558-8683       n                      www.tax.wv.gov