HTML Preview Business Activity Report page number 1.
(Read the instructions on the back to determine if you must file this form.)
If you need more space to complete any answers on this form, please print or type your answers on a separate sheet of paper.
West Virginia Department of Tax and Revenue
West Virginia Business Activity Report
For calendar year ___________, or fiscal year __________ to _____________.
Name of corporation or partnership
Street address
City or town State Zip Code
Principal office in West Virginia
Street address
City or town State Zip Code
Federal I.D. number
Have you made loans, or leases or
sales of products and services, in
West Virginia during the taxable
year?
Yes No
Principal types of business, products and services
State of
commercial
domicile
Offices and other places of business owned or maintained in West Virginia during the taxable year:
Locations (include full address if different from above) Type of activities for each location
Number of officers, employees, independent contractors, representatives or other agents with business activity in West Virginia on behalf of your
business.
Attach a brief job description for each officer and type of agent and indicate the number of each with any activity in this State regardless
of whether they reside or are regularly stationed in West Virginia.
Signature of officer or partner Name and Title of Person Signing Date Signed Daytime phone number
( )
Mail to: West Virginia Department of Tax and Revenue
Internal Auditing Division
P.O. Box 1202
Charleston, WV 25324-1202
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Please read instructions on back of this form carefully before completing this section and check all applicable boxes.
During the period covered by this report, did the corporation -
1. Own, rent, lease or maintain tangible or intangible personal property or real property in West Virginia? ............................
2. Employ or own any other assets in West Virginia? .................................................................................................................
3. Own or consign any merchandise located in West Virginia? .................................................................................................
4. Own assets located in West Virginia that are leased to others? ...........................................................................................
5. Perform any training, consultation, installation, or repair work in West Virginia? ..................................................................
6. Derive income from services performed for other businesses or persons located in West Virginia? .................................
7. Derive income from any source or activity within West Virginia, including income from activities conducted by
independent contractors, representatives or other agents, or by subsidiaries or affiliated entities? ...................................
8. Derive income or other receipts from any financial transactions in West Virginia, including: loans secured by real or
tangible property; consumer loans; commercial loans and installment obligations; syndication and participation loans;
credit card service charges and fees; credit card merchant discount income; performance of financial or fiduciary
services; travelers checks and money orders; and any other receipts not attributable to another state where the
organization is taxable. .............................................................................................................................................................
9. In any other way carry on business activity or maintain property within West Virginia
(as described on back of this form.)
Explain all "yes" answers in detail on a separate sheet. You may also be required to answer a West Virginia nexus questionnaire or otherwise
provide additional information if your explanations do not provide a clear picture of your taxability.
Yes No
By my signature I hereby certify that this report, including any accompanying material, is true, correct and complete to the best of my knowledge and belief.
West Virginia I.D. number
Are you a member of:
A unitary group?
Yes No
An affiliated group?
Yes No
Total amount of West Virginia sales (wholesale or retail) and /or
gross receipts attributable to West Virginia. $
Form
BAR-0
(Rev. 6/94)