STATE OF WEST VIRGINIA 
                State Tax Department, Tax Account Administration Div
                P. O. Box 3943
                Charleston, WV 25326-3943

                Name

                Address                                                                                             Account #:

                City                                                            State                 Zip

WV-1096                       ANNUAL SUMMARY AND TRANSMITTAL OF
rtL054  v 3-Web     W-2G BACKUP WITHHOLDING ON CERTAIN GAMBLING WINNINGS

TO BE FILED ON OR                                                                                                     Period Ending
BEFORE FEBRUARY 28
Name of person to contact     Telephone Number                                                           Fax Number   Email Address

1. Federal employer Id        2. Total number of                         3. Total withheld as shown                   4. Total backup withholding
number (FEIN)                 W-2G's                                     on W-2G                                      payments this year

                                                                                                                    .                             .
If you owe additional withholding, use WV-945V to pay.  If you have an overpayment and want a refund, submit an 
amended return(s) for the period(s) of overpayment, use form WV-945 and check the amended box.

                           Return this entire page to the West Virginia State Tax Department.
Under penalties of perjury, I declare that I have examined this return, accompanying schedules and statements, and to the best of my knowledge and belief, it is
true, correct and complete.

(Signature of Taxpayer)                                             (Print Your Name and Title)                                             (Date)

INSTRUCTIONS
Purpose of Form:  Use this form to transmit paper Forms W-2G  
to the West Virginia State Tax Department.  Do NOT use this form                                         Line 1:   Enter your Federal Employer ID number.
to transmit electronically.  For electronic submissions refer to My 
Taxes.                                                                                                   Line 2: Enter the total number of W-2G’s submitted 
                                                                                                                    with this transmittal.
Caution:  If you are required to file 50 or more of Form W-2G you 
must file electronically.  If you are required to file electronically                                    Line 3: Enter total dollar amount withheld as shown 
but fail to do so and you do not have an approved waiver you may                                                    on the W-2G’s submitted.
be subject to a penalty.
                                                                                                         Line 4: Enter the total of backup withholding payments
Who Must File:  The name, address and TIN of the filer on this                                                       made this year.
form must be the same as those you enter in the upper left area for 
form W-2G.  A filer is a person or entity who files any of these 
forms.

                MAIL TO:  WEST VIRGINIA STATE TAX DEPARTMENT
                           Tax Account Administration Div
                        P. O. Box 3943, Charleston, WV  25326-3943
                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                                                   B     7     3     2     0     1     1     0     1     W