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

WV/FSF-200              WEST VIRGINIA FIREWORKS SAFETY FEE RETURN
rtL326 v.1-Web

Period Ending:                                                                              Due Date:           Amended:
                                                                TAX COMPUTATIONS

1. Total Sales of Consumer Fireworks                                                                                    .
2. West Virginia Fireworks Safety Fee Rate                                                                              0.12
3. Total Amount Due (Multiply Line 1 by Line 2)                                                                         .

All retailers of consumer fireworks are required to collect a 12% safety fee as a part of the sales price in addition to any sales tax that 
may also be due. The fee must be remitted monthly on the Fireworks Safety Fee Return and is due on the 20th day after the end of a 
calendar month.

Instructions:
1.  Enter the total amount of consumer fireworks sold within the tax period (month) being reported.
2.  Multiply the total sales entered on line 1 by the applicable rate of the fee (12%).
3.  Enter the resulting Fireworks Safety Fee amount.

              MAIL TO:  WEST VIRGINIA STATE TAX DEPARTMENT
                        Tax Account Administration Div
                        P.O. Box 1826, Charleston, WV  25327-1826
   FOR ASSISTANCE CALL (304) 558-3333  TOLL FREE (800) 982-8297
              For more information visit our web site at: www.tax.wv.gov
                        File online at https://mytaxes.wvtax.gov

This return is not considered complete unless it is signed.
   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)
                                                                                                      B     4     7     0     6     1     6     0     1     W
Signature of Preparer   (Name of Preparer - Type or Print)       (Phone)                    (Date)