STATE OF WEST VIRGINIA
                                                                                                      
           State Tax Department, Charitable Bingo/Raffle Unit
                                                                                                      
           P.O. Box 1143
                                                                                                      
                                                                                                      Charleston, WV 25324-1143

           JIMMY J. JIMSON_____________________________________________________________                                                                                                                                  Letter Id:        L2107342848
                                                                                                      Name
                                                                                                      10_____________________________________________________________             JIM STREET                             AccountIssued:#: ________________11/23/2022
                                                                                                      AddressJIMTOWN WV  29181                                                                                           Account #:         2271-0791
                                                                                                      _____________________________________________________________
                                                                                                      City                                                                      State                        Zip
                                                                                                      
WV/RAFBRD-1                 LICENSE APPLICATION TO SELL RAFFLE BOARDS AND GAMES
rtL181 v.18

    Registration Year:                                        to                                                                                                                                                         Due Date:

           Check Type:        Wholesaler or Distributor                  Manufacturer                                                                                                                                    Manufacturer and Distributor                             
           Under West Virginia Code § 47-23 Wholesalers, Distributors or Manufacturers making sales to West Virginia Retailers
                                                must have a current Raffle Boards and Games License.
    The annual fee is $500.00 - Amount Enclosed                                                                                                                                                                                                                     .             
            Pursuant to West Virginia Code § 11-12, you are required to obtain a Business Registration Certificate.
            Additional information, including the Application for Registration Certificate (WV/BUS-APP),
                                                may be found by visiting our website at www.tax.wv.gov

    IF YOU ARE A NONRESIDENT SUPPLIER OF RAFFLE BOARDS AND GAMES TO WEST VIRGINIA
    RETAILERS, YOU MUST DESIGNATE A RESIDENT AGENT UPON WHOM NOTICE OF PROCESS
    MAY BE SERVED.  PLEASE FURNISH THE FOLLOWING INFORMATION:

    RESIDENT AGENT:                                                                                                                                                                                             TELEPHONE:
                                                                                                                                                                                                                           
    STREET:
            
    CITY:                                                                STATE:                                                                                                                                                    ZIP CODE:
                                                Complete and return this application and                                                                                                                        $500.00 remittance.          
                                                Make checks payable to West Virginia State Tax Department
            Should you have any questions, please contact the Charitable Bingo/Raffle Unit at (304) 558-8683
                              Make a photocopy of this application for your records before mailing it.
                                                                    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)                                                                                                                                 (E-mail Address)
 
    (Signature of preparer other than taxpayer)                          (Address)                                                                                                                                                         (Date)

            MAIL TO: WEST VIRGINIA STATE TAX DEPARTMENT
                              Charitable Bingo/Raffle Unit
                            P.O. Box 1143, Charleston, WV 25324-1143
                            FOR ASSISTANCE CALL (304) 558-8683
            For more information visit our web site at: www.tax.wv.gov
                                                                                                                                                                                                                          O     5     8     0     8     0     9     0     1     W