West Virginia Innovative Mine Safety 
                                                                                                          West Virginia 
උඐඍඌඝඔඍ IMSTTC-1                                Technology Tax Credit                                     State Tax 
S REV. 9/2020                                   (For periods AFTER January 1, 2020)                       Department

Taxpayer                                                      Business 
Name                                                          Name
Employer Identi fication Number (EIN):                               WV State Tax Department Tax Account ID:
                                                       ◄ OR ►

Street Address of Business

City, Town, or Post O  ffice                                      State                             Zip-Code

Tax year Beginning and Ending Dates: ____ / ____ / ________  to  ____ / ____ / ________
►       Taxpayers receiving an original allocation of West Virginia Innovative Mine Safety Technology Tax Credit from the
        West Virginia O  ffice of Miners’ Health, Safety and Training must complete Parts A and B of the Schedule. If a Taxpayer
        receiving an original allocation of West Virginia Innovative Mine Safety Technology Tax Credit is a Pass-Through
        Entity and any unused credit is to be passed through to the Entity’s Owner(s), then Part D must be completed also.
►       An owner Taxpayer receiving an unused allocation of West Virginia Innovative Mine Safety Technology Tax Credit
        from a Pass-Through Entity subsidiary must complete Parts A and C of the Schedule.

Under penalties of perjury, I declare that I have examined this tax credit claim form (including accompanying 
schedules and statements) and to the best of my knowledge it is true and accurate.

Signature of Authorized Taxpayer Representative                                               Date

Typed or Printed Name of Authorized Taxpayer Representative         Title

Telephone Number

Person to contact concerning this schedule (Name and Telephone Number)

Part A — Innovative Mine Safety Technology Tax Credit Summary

1. Current Year Innovative Mine Safety Technology Tax Credit Attributable to
Direct Allocations from the West Virginia O  ffi  ce of Miners’ Health, Safety
and Training (Enter the amount from Part B, Line 5 (Amounts not sup-
ported by completed Part B will be disallowed)............................................   $

2. Current Year Innovative Mine Safety Technology Tax Credit Allocated to
the Owner of a Pass-Through Entity that received a direct allocation of
the tax credit from the West Virginia O  ffice of Miners’ Health, Safety and
Training (Enter the amount from Part C, Line 1. Total (Amounts not sup-
ported by completed Part C will be disallowed)............................................   $

3. Total Current Year Innovative Mine Safety Technology Tax Credit (Add the
amounts on Line 1 and 2 and enter here...................................................... $
Continued on the next page…
Schedule IMSTTC-1
                                West Virginia Innovative Mine Safety Technology Tax Credit                 Page 1 of 5
Rev. 9/2020

Taxpayer Name:                                                   EIN or WV State Tax Department Tax Account ID:

Part A — Continued

4.A) Total Corporation Net Income Tax (Before Application of Any Tax 
     Credits {Taxpayers whose Innovative Mine Safety Technology Tax 
     Credit is entirely attributable to allocation from a Pass-Through Entity 
     enter only the Corporation Net Income Tax Imposed on the conduit 
     income directly derived from the Pass-Through Entity})..........................                     $
B) Maximum Annual O ff  set of Corporation Net Income Tax by the 
     Innovative Mine Safety Technology Tax Credit (Multiply the amount on 
     Line 4A by 0.50 {50%} and enter here)...................................................             $
C) Maximum Innovative Mine Safety Technology Tax Credit that can be 
     used in any tax year by any Taxpayer in combination with the Owners 
     of the eligible Taxpayer (Enter an amount equal to $100,000 less the 
     amount on Line 3)................................................................................... $
D) Innovative Mine Safety Technology Tax Credit to be applied to Reduce 
     Corporation Net Income Tax Liability (Enter the lesser of the amounts 
     on Lines 3, Line 4B, Line 4C, if less than 0 {zero}, enter 0. Also, enter 
     this value on the Summary of Tax Credits Schedule {CIT-120TC or 
     PTE-100 TC, as appropriate)...................................................................       $
5.  Available Innovative Mine Safety Technology Tax Credit Adjusted for 
 Corporation Net Income Tax (Subtract the amount on Line 4D from the 
 amount on Line 3 and enter here)................................................................         $
6.  Unused Innovative Mine Safety Technology Tax Credit to be allocated. If 
 the Taxpayer is a Pass-Through entity and any of the amount on Line 5 is 
 to be allocated to the owners of the Pass-Through entity, complete Part D 
 and enter the total amount of credit to be allocated here.............................                   $

Schedule IMSTTC-1
                           West Virginia Innovative Mine Safety Technology Tax Credit                      Page 2 of 5
Rev. 9/2020

Taxpayer Name:                                               EIN or WV State Tax Department Tax Account ID:

Part B — Innovative Mine Safety Technology Tax Credit Allocated by Of fi                                        ce of 
           Miners’ Health, Safety and Training (OMHST)

1. Current Year Allocation of West Virginia Innovative Mine Safety Technology Tax Credit (IMSTTC) from the West 
Virginia O  ffice of Miners’ Health, Safety and Training:

A.  Date of Certi fication.............................................................................

B.  Amount of Innovative Mine Safety Technology Credit Allocated Per 
     the Above O  ffice of Miners’ Health, Safety and Training Certi fication                                    $
C.  Annual Amount of Innovative Mine Safety Technology Credit 
     available for use in the current tax year and the next succeeding 
     four tax years (Divide the amount on Line 1B by 5 and enter here)...                                     $
2.  Total Annual Innovative Mine Safety Technology Tax Credit Available from prior years:

A.  One Year Prior Annual IMSTTC (from Part B, Line 1C of 1 year prior 
     IMSTTC-1 form)..................................................................................         $

B.  Two Years Prior Annual IMSTTC (from Part B, Line 1C of 2 years 
     prior IMSTTC-1 form).........................................................................            $

C.  Three Years Prior Annual IMSTTC (from Part B, Line 1C of 3 years 
     prior IMSTTC-1 form).........................................................................            $

D.  Four Years Prior Annual IMSTTC (from Part B, Line 1C of 4 years 
     prior IMSTTC-1 form).........................................................................            $

E.  Total (Sum Lines 2A, 2B, 2C, and 2D and enter here)........................                               $

3.  Total Annual Innovative Mine Safety Technology Tax Credit Available (Add 
the amounts on Line 1C and Line 2E and enter here).................................                           $
4.  Maximum Innovative Mine Safety Technology Tax Credit that can be used 
in any tax year by any Taxpayer in combination with the Owners of the 
eligible Taxpayer...........................................................................................  $
                                                                                                               100,000.00
5.  Innovative Mine Safety Technology Tax Credit Available for use This tax 
period (Enter the lesser of the amount on Line 3 and Line 4 here and on 
Part A. Line 1).............................................................................................. $

Schedule IMSTTC-1
                           West Virginia Innovative Mine Safety Technology Tax Credit                             Page 3 of 5
Rev. 9/2020

Taxpayer Name:                    EIN or WV State Tax Department Tax Account ID:

Part C — Innovative Mine Safety Technology Tax Credit (IMSTTC) Received from 
           a Pass-Through Entity in which the Taxpayer has an Ownership Interest
                         Pass-Through Entity
                         Employer Identi fication Amount of IMSTTC
Pass-Through Entity Name Number (EIN)                                       Allocated

                                                $

                                                $

                                                $

                                                $

                                                $

                                                $

                                                $

                                                $

                                                $

                                                $

                                                $

1. Total                                        $

Schedule IMSTTC-1
                 West Virginia Innovative Mine Safety Technology Tax Credit          Page 4 of 5
Rev. 9/2020

Taxpayer Name:                                                      EIN or WV State Tax Department Tax Account ID:

Part D — Current Year Unused Innovative Mine Safety Technology Tax Credit 
           (IMSTTC) to be Allocated to Owners
1.  Current Year Allocation of West Virginia Innovative Mine Safety 
Technology Tax Credit (IMSTTC) from the West Virginia O  ffice of Miners’ 
Health, Safety and Training (Enter the value from Part B Line 3)................              $
2.  Maximum Innovative Mine Safety Technology Tax Credit that can be used 
in any tax year by any Taxpayer in combination with the Owners of the 
eligible Taxpayer (Enter the lesser of $100,000 and the amount on Line 1)                     $
3.  Amount used by the Taxpayer to reduce Corporation Net Income Tax 
(Enter the amount from Part A Line 4D)....................................................... $
4.  Adjusted amount for potential allocation to owners (Enter the Result from 
subtracting the value on Line 3 from the value on Line 2)............................         $

***Pass-Through Entities (i.e., small business corporations, limited liability companies, partnerships and other 
unincorporated organizations) shall allocate any unused credit after the Pass-Through Entities application of the 
credit against the Corporation Net Income Tax among their members in the same manner as pro fi  ts and losses are 
allocated for the taxable year.***

Innovative Mine Safety Technology Tax Credit Allocation to Owners
                                                                                               Amount of IMSTTC
           Owner Name               Owner EIN             Ownership %                          Allocated

                                                                      %$

                                                                      %$

                                                                      %$

                                                                      %$

                                                                      %$

                                                                      %$

                                                                      %$

                                                                      %$

                                                                      %$

                                                                      %$

Schedule IMSTTC-1
                      West Virginia Innovative Mine Safety Technology Tax Credit                        Page 5 of 5
Rev. 9/2020