SCHEDULE                                                APPLICATION FOR 
   SAAM-A             WV TAX CREDIT FOR FEDERAL EXCISE TAX IMPOSED UPON                                                  West Virginia 
                                                                                                                         State Tax Department
   REV10/2021                  SMALL ARMS AND AMMUNITION MANUFACTURERS
                                                           (FOR PERIODS ON OR AFTER JULY 1, 2021)
        NOTE: AN APPLICATION MUST BE FI LED FOR EACH YEAR IN WHICH INVESTMENT FOR PURPOSE OF THIS TAX CREDIT IS PLACED IN SERVICE OR USE. 
                  ADDITIONALLY, THE APPLICATION MUST BE APPROVED BY THE STATE TAX COMMISSIONER BEFORE ANY CREDIT MAY BE CLAIMED
                                         SECTION A: BUSINESS IDENTIFICATION 
1  FEIN                                                                   WV TAX ID
                                                                 TAX PERIOD
2  BEGINNING                                                              ENDING
                   MM             DD                       YYYY                                  MM      DD                     YYYY
   BUSINESS NAME
3
   TAXPAYER NAME 
4

                                         SECTION B: INVESTMENT INFORMATION
5       INVESTMENT PURPOSE                   INDUSTRIAL  EXPANSION         INDUSTRIAL REVITALIZATION            BOTH INDUSTRIAL 
              (CHECK ONLY 1)                                                                                    EXPANSION AND REVITALIZATION
   A) BUSINESS ACTIVITY IN WEST VIRGINIA: NORTH AMERICAN INDUSTRY CLASSIFICATION SYSTEM CODE (NAICS)
   B) NARRATIVE DESCRIPTION OF BUSINESS ACTIVITY IN WEST VIRGINIA
6

7  INVESTMENT YEAR                       TOTAL INVESTMENT                                             QUALIFIED 
                                         AMOUNT $                                                     INVESTMENT $
   LOCATION(S) OF 
8  INVESTMENT  IN 
   WEST VIRGINIA
    GENERAL DESCRIPTION OF QUALIFIED INVESTMENT (NARRATIVE):
9

                                  SECTION C: ADDITIONAL REQUIRED INFORMATION
                                                                          PAYROLL                                 JOBS
10 A) TOTAL WV PAYROLL AND NUMBER OF JOBS PRIOR TO INVESTMENT
   B) TOTAL WV PAYROLL AND NUMBER OF JOBS THIS YEAR

   A) PERCENTAGE OF EMPLOYEES COVERED UNDER HEALTH PLANS:                                                                                    %
   B) AVERAGE ANNUAL HEALTH PLAN BENEFIT COSTS PER EMPLOYEE:
11
   C) PERCENTAGE OF EMPLOYEES COVERED UNDER RETIREMENT PLAN:                                                                                 %
   D) AVERAGE ANNUAL RETIREMENT BENEFIT COST PER EMPLOYEE:
                               SECTION D: COMPUTATION OF QUALIFIED INVESTMENT
ITEMIZED LISTING OF INVESTMENTS REQUIRED
   INVESTMENTS THIS YEAR                                         A                                  B                           C 
                                                                 NET COST                        RATE                    ALLOWABLE COST 
1  INVESTMENT WITH USEFUL LIFE OF                                                                33 ⅓%
   AT LEAST 4 YEARS BUT LESS THAN 6 YEARS
2  INVESTMENT WITH USEFUL LIFE OF                                                                66 ⅔%
   AT LEAST 6 YEARS BUT LESS THAN 8 YEARS
3  INVESTMENT WITH USEFUL LIFE OF 8 YEARS OR MORE                                                   100% 
4  TOTAL QUALIFIED INVESTMENT FOR THIS TAX YEAR (SUM OF COLUMN C)
                                                                 SIGNATURE
Under penalties of perjury, I declare that I have examined this credit claim form (including accompanying schedules and statements) and to the best of my knowledge it is true and complete.

        SIGNATURE OF TAXPAYER                               NAME OF TAXPAYER (PRINT OR TYPE)                      TITLE           DATE

   SIGNATURE OF PREPARER OTHER THAN TAXPAYER                       ADDRESS                                        DATE

   PERSON TO CONTACT CONCERNING THIS RETURN                                                                     TELEPHONE

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SCHEDULE SAAM-A (continued) 

                            INVESTMENT LISTING
                            (USE ADDITIONAL SHEETS IF NECESSARY)
NAME OR DESCRIPTION OF ITEM PURPOSE      DATE ACQUIRED/         USEFUL NET COST
(LIST SEPARATELY)                        PLACED IN SERVICE      LIFE

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