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

    Name

    Address                                                                                        Account #:

    City                                                            State                 Zip
                                                                                                                            File and pay online at
                                                                                                                            MyTaxes.WVtax.gov.
WV/CST-200CU                                                                                                                For additional forms or
rtL142V.4-Web                               WEST VIRGINIA SALES AND USE TAX RETURN                                          information visit us at
                                                                                                                            www.wvtax.gov

Period Ending:                                             Due Date:                                                        Amended

    Consumer Sales and Services Tax                   Complete schedules A & B (if applicable) before completing this return
1.  Total state sales tax due from Schedule A, Part I, line 9
2.  Total sales tax due on sales of wine/liquor to private clubs from Schedule A, Part II, line 3
3.  Total municipal sales tax due from Schedule B, line 31
4.  Total Sales Tax due  (add lines 1 through 3)

    Use Tax       Complete schedules A & C (if applicable) before completing this return
5.  Total state use tax due from Schedule A, Part III, line 3
6.  Total municipal use tax due from Schedule C, line 31
7.  Total Use Tax due  (add lines 5 and 6)

          Total West Virginia Sales and Use Tax Due
8.  Enter total sales tax due from line 4
9.  Enter total use tax due from line 7
10. Total tax due  (add lines 8 and 9)
11. Enter any tax collected in excess of line 10
12. Interest
13. Additions to tax
14. Sales/Use Tax Credit* (please specify)  Credit must be previously approved by Tax Department
15. Total amount due    (add lines 10 through 13 and subtract line 14)
    *Credit is issued from either a previously filed return on which you stated that a credit would be taken on next monthly return or from an application for credit approved by the Tax Department.

   OASIS Transfer Sheet attached            Credit/Refund Application attached                     Bad Debt Deduction Taken (appropriate documentation must be attached)

 PART IV - Sign your Return
Under penalties of perjury, I declare that I have examined this return (including accompanying  
schedules and statements) and to the best of my knowledge and belief it is true, and complete.

(Signature of Taxpayer) (Name of Taxpayer - Type or Print) (Title)                           (Date)

(Person to Contact Concerning this Return)            (Telephone Number)
                                                                                                   G     1     5     2     0     1     3     0     1      W
(Signature of preparer other than taxpayer) (Address)                                        (Date)

Schedule A - Sales and Use Tax - State   (additional blank copies may be obtained on our website www.wvtax.gov)

Part I   Sales Tax - State
(Do not include sales of wine/liquor to private clubs in this part)
1.  Total sales (do not include tax)
2.  Sales for which an exemption certificate and/or direct pay permit was received
3.  Sales of food and food ingredients
4.  Other deductions/exemptions
    (prescription items, sales returns, allowances and bad debt etc.)
5.  Total deductions/exemptions  (add lines 2 through 4)
6. Sales subject to state sales tax
    (subtract line 5 from line 1)  (If line 5 is greater than line 1, proceed to line 7.)
7. Sales subject to state sales tax credit
    (If line 5 is greater than line 1, subtract line 1 from line 5)
8.  State Sales Tax rate                                                                                             0.06
9.  Sales Tax due  (multiply line 6 by line 8)
10. Credit of sales tax
    (multiply line 7 by line 8)  (If line 5 is greater than line 1, you are entitled to a credit of sales tax.)
11. Total refund  (To obtain a refund, enter the total from line 10.)
12. Credit due    (To take credit on next monthly return, enter the total from line 10.)

Part II   Sales Tax - State on
Sales of Wine/Liquor to Private Clubs
(Do not include sales other than of wine/liquor in this part)
1.  Total sales (do not include tax)
2.  State Sales Tax rate                                                                                             0.06
3.  Total State Sales Tax on sales of wine/liquor to private clubs                       (multiply line 1 by line 2)

Part III   Use Tax - State  
1.  Purchases subject to state use tax
2.  State Use Tax rate                                                                                               0.06
3.  Total State Use Tax due (multiply line 1 by line 2)
4. Payment made with original return          (enter only if return is amended)
5. Total refund   (If amended return and line 4 is greater than line 3, enter amount to be refunded.)
6. Credit due   (If amended return and line 4 is greater than line 3, enter amount to be credited to future periods.)

                   File and pay online at
                   MyTaxes.WVtax.gov.
                   For additional forms or
                   information visit us at
                       www.wvtax.gov                                                                           G     1     5     2     0     1     3     0     2      W

   Schedule B - Sales Tax - Municipal     (additional blank copies may be obtained on our website www.wvtax.gov)
   A                                    B              C                   D                        E
                                                       Sales subject to    Tax                      Municipal Tax Due
   Municipal Code                City/Town Name - FIPS Municipal Sales Tax Rate                     (sales x tax rate)
1  54232                   Williamstown   87556                            0.010
2  06020                   Huntington     39460                            0.010
3  13044                   Rupert         70828                            0.010
4  43197                   Harrisville    35428                            0.010
5  35157                   Wheeling       86452                            0.010
6  13040                   Quinwood       66412                            0.010
7  20072                   Charleston     14600                            0.010
8  19065                   Bolivar        08932                            0.010
9  19066                   Charles Town   14610                            0.010
10 02005                   Martinsburg    52060                            0.010
11 06021                   Milton         54484                            0.010
12 20081                   Nitro          59068                            0.010
13 54230                   Parkersburg    62140                            0.010
14 19068                   Ranson         66988                            0.010
15 47209                   Thomas         80020                            0.010
16 54231                   Vienna         83500                            0.010
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31 Total Municipal Sales Tax Due  (add lines 1 through 30 and enter here and on Consumers Sales and 
   Use Tax Return,  line 3)

         File and pay online at
         MyTaxes.WVtax.gov.
         For additional forms or
         information visit us at
                  www.wvtax.gov                                            G     1     5     2     0     1     3     0     3      W

   Schedule C - Use Tax - Municipal      (additional blank copies may be obtained on our website www.wvtax.gov)
   A                                   B              C                    D                      E
                                                      Purchases subject to Tax                    Municipal Tax Due
   Municipal Code               City/Town Name - FIPS Municipal Use Tax    Rate                   (purchases x tax rate)
1  54232                  Williamstown   87556                             0.010
2  06020                  Huntington     39460                             0.010
3  13044                  Rupert         70828                             0.010
4  43197                  Harrisville    35428                             0.010
5  35157                  Wheeling       86452                             0.010
6  13040                  Quinwood       66412                             0.010
7  20072                  Charleston     14600                             0.010
8  19065                  Bolivar        08932                             0.010
9  19066                  Charles Town   14610                             0.010
10 02005                  Martinsburg    52060                             0.010
11 06021                  Milton         54484                             0.010
12 20081                  Nitro          59068                             0.010
13 54230                  Parkersburg    62140                             0.010
14 19068                  Ranson         66988                             0.010
15 47209                  Thomas         80020                             0.010
16 54231                  Vienna         83500                             0.010
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31 Total Municipal Use Tax Due  (add lines 1 through 30 and enter here and on Consumers Sales and 
   Use Tax Return, line 6)

         File and pay online at
         MyTaxes.WVtax.gov.
         For additional forms or
         information visit us at
                  www.wvtax.gov                                            G     1     5     2     0     1     3     0     4      W