STATE OF WEST VIRGINIA 
State Tax Department, Tax Account Administration Div
P.O. Box 1826
Charleston, WV 25327-1826

rtL036 v.9-Web

                      WEST VIRGINIA FACTORY-BUILT HOMES FEE

Effective January 1, 2008, the Factory-Built Homes Fee as provided for by W.Va. Code § 11-15-4c is due 
the 20th day of the month following the period reported.  The reporting period is the same reporting period 
as your Consumers Sales and Service Tax return.

Taxpayers required to file electronically will no longer receive returns for the tax types subject to the 
mandatory requirement by mail.  Please visit www.wvtax.gov for additional information.

              IF YOU HAVE ANY QUESTIONS CALL                                                 MAKE CHECK PAYABLE TO AND MAIL TO:
                      (304) 558-3333                                                         WV STATE TAX DEPARTMENT
                      OR                                                                     INTERNAL AUDITING DIVISION
                  1-800-982-8297 TOLL FREE                                                                       PO BOX 1826
                                                                                             CHARLESTON WV  25327-1826

                      PLEASE CUT HERE.  USE BLUE OR BLACK INK TO COMPLETE VOUCHER.  DO NOT WRITE IN BARCODE AREA.

                                           FACTORY-BUILT HOMES FEE

              Period:                Account ID #                                                                             WV/FBH-100 v. 9-Web

              Due:

                                                                                             1. NUMBER OF FACTORY-BUILT HOMES SOLD

              Name                                                                           2. TOTAL FEE DUE    $          ,     .
                                                                                                (Line 1 x $20.00)

              Address

              City                                                 State                 Zip SIGNATURE                            DATE

              00000004838403