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

            JIMMY J. JIMSON_____________________________________________________________                                                                                                                                 Letter Id:        L0060522496
                                                                                                      Name
                                                                                                      10_____________________________________________________________             JIM STREET                             AccountIssued:#: ________________11/23/2022
                                                                                                      AddressJIMTOWN WV  29181                                                                                           Account #:              2271-0791
                                                                                                      _____________________________________________________________
                                                                                                      City                                                                      State                        Zip
                                                                                                      
WV/RAFBRD-3
rtL182 v.21                 RAFFLE BOARDS AND GAMES QUARTERLY RETURN

      Filing Period:                                        to                                                                                                                                                           Due Date:

            THIS FORM MUST BE COMPLETED AND RETURNED EVEN THOUGH NO FEES ARE DUE

                                               SECTION 1 - FEE CALCULATION                                                                                                                                                                                                       
   1. Total Sales of Raffle Boards and Games to Retailers in West Virginia for this Quarter 
                                                                                                                                                                                                                                                                    .
   2. Rate
                                                                                                                                                                                                                                                          0.20
   3. Fee Due (Multiply Line 1 by Line 2)
                                                                                                                                                                                                                                                                    .
   4. Non-Waivable Interest
                                                                                                                                                                                                                                                                    .
   5. Additions to Tax
                                                                                                                                                                                                                                                                    .
   6. Total Tax Due (Add Lines 3, 4 and 5)
                                                                                                                                                                                                                                                                    .
 
            FOR ASSISTANCE, CALL THE BINGO AND RAFFLE UNIT AT (304) 558-8683

                                               SECTION 2 - CERTIFICATION TO REPORT                                                                                                                                                                                               
   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)                                                                                                                                             (Email Address)

   (Signature of preparer other than taxpayer)                        (Address)                                                                                                                                                            (Date)
 
                           PLEASE SEE INSTRUCTIONS ON REVERSE SIDE OF RETURN

            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     1     3     0     8     0     9     0     1     W

WV/RAFBRD-3
rtL182 v.21 RAFFLE BOARDS AND GAMES QUARTERLY RETURN
                                                                                                      Letter Id:  L0060522496

Line 1 Enter on this line the total dollar amount, retail value, for sales and/or any shipments of raffle boards and games
            to West Virginia retailers (other than organizations with an exemption letter from the Department of Tax and
            and Revenue).  Under West Virginia Code § 47-21-3, certain charitable or public service organizatons are exempt
            from the Raffle License Fee and, under West Virginia Code § 47-23-2(d), exempt from the raffle board fee,
            providing that the retailer presents a current exemption document form the Tax Department.

Line 2      Fee imposed on sales of raffle boards and games.

Line 3      Enter on this line the total fee due by multiplying Line 1 by Line 2.

Line 4      The annual interest rate will never be less than 8%.  For the current interest rate, contact Taxpayer Services
            Division (304) 558-2068 or toll free within West Virginia 1-800-422-2075.  Request Message Number 510.

Line 5      The rate for late filing is 5% per month or any part of a month.  The rate for late payment of fee is one half of one
            percent per month or any part of a month.  The maximum under either penalty is 25%.  The maximum for both
            penalties is 50% of the fee due.

Line 6      Enter on this line Total Fee Due (Add Lines 3, 4 and 5).

"Wholesalers or Distributors" and "Manufacturers and Distributors" must enclose all sales invoices, including sales invoices
to organizations with a current exemption letter, when filing this Quarter Period Return.  Manufacturers selling to distributors
or wholesalers only would not be liable for the fee.  However, manufacturers would be required to file the return and
enclose all sales invoices to distributors and wholesalers.

            MAKE CHECK PAYABLE TO:  WEST VIRGINIA STATE TAX DEPARTMENT
            MAKE A PHOTOCOPY OF THE RETURN FOR YOUR RECORDS

            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
                                            CHARITABLE BINGO/RAFFLE UNIT

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