STATE OF WEST VIRGINIA 
    State Tax Department, Tax Account Administration Div
    P.O. Box 3802
    Charleston, WV 25338-3802

    Name

    Address                                                                                                          Account #:

    City                                                            State                 Zip
                               WEST VIRGINIA SPECIAL DISTRICT EXCISE RETURN
WV/rtL002  v 1-Web                          Monongalia County - University Town Center

Period Ending:                                                   Due Date:                                                       Amended Return
Part I   Special District Excise Tax
1.  Total sales    (do not include tax)                                                                                        1
2.  Sales for which an exemption certificate and/or direct pay permit was received                                             2
3.  Sales of food and food ingredients                                                                                         3
4.  Other deductions/exemptions             (food stamps, prescription items, sales returns, allowances and bad debt, etc.)    4
5.  Total deductions/exemptions  (add lines 2 through 4)                                                                       5
6. Sales subject to tax        (subtract line 5 from line 1)  (If line 5 is greater than line 1, proceed to line 7.)           6
7. Sales subject to tax credit (If line 5 is greater than line 1, subtract line 1 from line 5)                                 7
8.  Tax rate                                                                                                                   8       0.06
9.  Sales Tax due  (multiply line 6 by line 8)                                                                                 9
10. Credit of tax  (multiply line 7 by line 8)  (If line 5 is greater than line 1, you are entitled to a credit of sales tax.) 10
11. Total refund   (To obtain a refund, enter the total from line 10.)                                                         11
12. Credit due     (To take credit on next monthly return, enter the total from line 10.)                                      12
Part II   Total Amount Due
13. Total tax from line 9      (If line 10 is greater than line 9, enter 0.00)                                                 13
14. Enter any tax collected in excess of line 13                                                                               14
15. Interest                                                                                                                   15
16. Additions to tax                                                                                                           16
17. Total amount due           (add lines 13 through 16)                                                                       17
Part III   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)

(Signature of preparer other than taxpayer)    (Address)                                       (Date)

                   MAIL TO:  WEST VIRGINIA STATE TAX DEPARTMENT
                               Tax Account Administration Div
                        P.O. Box 3802, Charleston, WV  25338-3802
    FOR ASSISTANCE CALL (304) 558-3333  TOLL FREE (800) 982-8297
                   For more information visit our web site at: www.wvtax.gov
                        File online at https://mytaxes.wvtax.gov                                                     O     8     2     2     0     1      3     0      1      W