STATE OF WEST VIRGINIA
                                                                                                 
           State Tax Department, Tax Account Administration Div
                                                                                                 
           P.O. Box 2666 
                                                               Charleston, WV 25330-2666

                                                                                                 _____________________________________________________________
                                                        NameTEST CORPORATION 1                                                                                                        Letter Id: L0947142656
                                                                                                 1001_____________________________________________________________           LEE ST E Issued:    04/01/2019
                                                                      AddressCHARLESTON WV  25301-1725                                                                                Account #:         2270-3780
                                                                                                 _____________________________________________________________                        Period:    06/30/2019
           City                                                                      State                        Zip
                                                                                                 
                                                                              WEST VIRGINIA REGISTRATION APPLICATION FOR
WV/CEM-1                                                                                                     CEMETERIES
REV02-19                 Account                                                                      PERIOD                                                  PERIOD                             DUE DATE
                         #                                                              STARTING                                                              ENDING                             MMDDYYYY
                                                                                        MMDDYYYY
ANNUAL                   OWNERSHIP OR COMPLIANCE AGENT CHANGES
REGISTRATION             SECTION 2 REQUIRED                                                                          AMOUNT DUE   
$200.00                  $100.00
No person, partnership, firm or corporation may engage in the business of operating a cemetery company in this state without having first paid an annual registration fee of two hundred dollars ($200.00)
and filing with the tax commissioner certain information, which shall include the name and addresses of all officers, owners and directors of the cemetery company and the name of the designated
compliance agent. The cemetery company shall notify the tax commissioner of any changes in the information required to be filed within ninety days of the date on which the change occurs. A new filing
shall also be required if there is a change in the ownership of the cemetery company, or if there is a change in the name of the compliance agent designated by the cemetery company. The cemetery
company shall pay an additional fee of one hundred dollars ($100.00) when reporting such changes. This also includes certain funeral homes and sellers of memorials. Questions on reverse side of
application must be completed. Taxpayers required to file electronically will no longer receive returns for the tax types subject to the mandatory requirement by mail.   
DATE CEMETERY                                                                                                       PLEASE FURNISH YOUR FISCAL
COMMENCED BUSINESS:                                                                                                  YEAR END DATE:
MMDDYYYY
                  SECTION 1:  BUSINESS DESCRIPTION  Complete the form below by checking all boxes that apply

I MAINTAIN A MORTUARY IN CONNECTION WITH THIS                                                         THIS CEMETERY IS INCORPORATED
CEMETERY
 THIS CEMETERY IS OWNED OR OPERATED BY A:
COUNTY              MUNICIPAL CORPORATION                                                             CHURCH         NONSTOCK CORPORATION NOT OPERATED FOR PROFIT

IF YOU CHECKED ANY OF THE ABOVE, DOES THIS CEMETERY DO ANY OF THE FOLLOWING:
           COMPENSATE ANY OFFICER OR DIRECTOR EXCEPT FOR REIMBURSEMENT OF REASONABLE EXPENSES INCURRED IN THE PERFORMANCE OF OFFICIAL 
           DUTIES?
           SELL OR CONSTRUCT OR DIRECTLY OR INDIRECTLY CONTRACT FOR THE SALE OF CONSTRUCTION OF VAULTS OR LAWN OR MAUSOLEUM CRYPTS?

           USE PROCEEDS FROM THE SALE OF ALL GRAVES AND ENTOMBMENT RIGHTS FOR OTHER THAN THE SOLE PURPOSE OF DEFRAYING THE DIRECT EXPENSES OF 
           MAINTAINING THE CEMETERY?
THIS CEMETERY IS A COMMUNITY CEMETERY NOT OPERATED FOR PROFIT THAT DOES NOT COMPENSATE ANY OFFICER, OWNER OR DIRECTOR EXCEPT FOR 
REIMBURSEMENT OF REASONABLE EXPENSES INCURRED IN THE PERFORMANCE OF OFFICIAL DUTIES, AND USES THE PROCEEDS FROM THE SALE OF THE GRAVES 
THIS CEMETERY IS A FAMILY CEMETERY WHEREIN LOTS OR SPACES ARE NOT OFFERED FOR PUBLIC SALE.

 I HAVE A PRENEED SALES PROGRAM FOR (CHECK ALL THAT APPLY):
LOTS              VAULTS                  BRONZE                                    MAUSOLEUM                LAWN                                              OPEN/CLOSING OF                   MEMORIALS MARKER 
                                                                                    CRYPTS                   CRYPTS                                            GRAVE                                       BASES
 TOTAL ACREAGE OF                                                                                                    NUMBER OF ACRES NOW
 CEMETERY:                                                                                                           DEVELOPED SO THAT BURIALS
                                                                                                                     CAN BE MADE THEREIN:
                                                  NAME                                                               PO BOX/STREET ADDRESS, CITY, STATE, ZIP CODE
I HAVE AN ESTABLISHED TRUST FUND(S) 
FOR THE PROCEEDS FROM SALES OF SUCH 
PRENEED ITEMS OR SERVICES

MAIL TO:          WEST VIRGINIA STATE TAX DEPARTMENT  
                  Tax Account Administration Div  
                  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.tax.wv.gov  
File online at https://mytaxes.wvtax.gov  
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  WV/CEM-1            WEST VIRGINIA REGISTRATION APPLICATION FOR CEMETERIES            ACCOUNT #
  CONTINUED
                         SECTION 2:  OFFICER, OWNER, DIRECTOR, COMPLIANCE AGENT INFORMATION
   OWNER/OFFICER NAME                                                                             SSN

1   STREET ADDRESS                                                                       CITY     STATE   ZIP/POSTAL CODE

   OWNER/OFFICER NAME                                                                             SSN

2
   STREET ADDRESS                                                                        CITY     STATE   ZIP/POSTAL CODE

   OWNER/OFFICER NAME                                                                             SSN

3
   STREET ADDRESS                                                                        CITY     STATE   ZIP/POSTAL CODE

   DIRECTOR NAME                                                                                  SSN

4
   STREET ADDRESS                                                                        CITY     STATE   ZIP/POSTAL CODE

   DIRECTOR NAME                                                                                  SSN

5
   STREET ADDRESS                                                                        CITY     STATE   ZIP/POSTAL CODE

   COMPLIANCE AGENT NAME                                                                          SSN

6
   STREET ADDRESS                                                                        CITY     STATE   ZIP/POSTAL CODE

                         SECTION 3:  SIGNATURE
  THIS REGISTRATION FORM MUST BE SIGNED BY A RESPONSIBLE PARTY WHO IS AUTHORIZED TO SIGN ON BEHALF OF THE ORGANIZATION.
  THE PROPRIETOR MUST SIGN FOR A SOLE PROPRIETORSHIP.
  Under penalty of perjury, I declare that I have examined this application, accompanying documents, and statements, and to the best of my knowledge and belief, it is true, correct and complete.

  SIGNATUIRE                                           PHONE                                      DATE

  PRINT NAME                                           EMAIL ADDRESS
  Make a photocopy of the application before mailing it in the envelope provided.
  The photocopy will be used as proof of registration until your certificate is issued.

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