VFTC-1              WEST VIRGINIA VOLUNTEER FIREFIGHTER                                                                                             West Virginia  
                                                                                                                                                      Tax Division
  REV08/2023                                           TAX CREDIT
                                               (FOR PERIODS ON OR AFTER JANUARY 1, 2023)
     FOR MARRIED JOINT FILERS, IF BOTH PRIME AND SPOUSE ARE VOLUNTEER FIREFIGHTERS, COMPLETE THIS FORM FOR EACH. FILE WITH YOUR IT-140 

                                   SECTION A: FIREFIGHTER IDENTIFICATION 
1 SSN

  FIRST NAME
2
  LAST NAME

                                                            TAX PERIOD
3 BEGINNING                                                                 ENDING
                      MM        DD                     YYYY                             MM                DD                                          YYYY

     SECTION B: CERTIFICATION FROM THE CHIEF OF THE VOLUNTEER FIRE DEPARTMENT 
4 RANK OF VOLUNTEER

5 YEARS OF SERVICE

6 THE NUMBER OF EMERGENCY SITUATIONS  TO WHICH  THE VOLUNTEER 
  FIREFIGHTER RESPONDED IN THE YEAR OF ACTIVE MEMBERSHIP
7 THE  NUMBER  OF  EMERGENCY  SITUATIONS  TO  WHICH  THE  FIRE  DEPARTMENT 
  RESPONDED IN THE YEAR OF ACTIVE MEMBERSHIP
8 THE NUMBER OF MEETINGS OR  TRAINING  ATTENDED BY  THE VOLUNTEER
  FIREFIGHTER IN THE YEAR OF ACTIVE MEMBERSHIP.
9 THE NUMBER OF MEETINGS AND TRAININGS HELD BY THE FIRE DEPARTMENT IN
  THE YEAR OF ACTIVE MEMBERSHIP.
  Under penalty of perjury, I declare that the above named is 
  •  A volunteer firefighter who has been an active member in good standing of the volunteer fire department for the
     entire year; or has been an active member in good standing of the volunteer fire department and another volunteer
     fire department of this state for the entire year; and
  •  Has participated as an active member as defined in §11-13JJ-3 of this code on-site at least 30 percent of the
     volunteer fire department activities during the year; and
  •  Has met or exceeded all certification and training for active member firefighters required under the laws of this
10
     state.

  SIGNATURE OF CHIEF OF THE VOLUNTEER FIRE DEPARTMENT                       NAME OF CHIEF (PRINT OR TYPE)                                             DATE

  ADDRESS OF FIRE DEPARTMENT LOCATION IN WEST VIRGINIA                      CITY                                                                STATE ZIP

                                            SECTION C: TAXPAYER SIGNATURE
Under penalty of perjury, I declare that I have examined this form and to the best of my knowledge and belief, it is true, correct and complete.Credit Schedule for reference 

SIGNATURE OF TAXPAYER                          NAME OF TAXPAYER (PRINT OR TYPE)            TITLE                                                      DATE
                      Do Not Send for forms testing 
  IF YOU HAVE ANY QUESTIONS OR NEED FURTHER INFORMATION REGARDING THIS FORM, 
  TELEPHONE (304) 558-3333, OR TOLL FREE TO 1-800-WVA-TAXS (1-800-982-8297).