WV/IT-101V         Employer's West Virginia Income Tax Withheld
                                  WV State Tax Department
                                                                                          PO Box 1667
                                  Charleston, WV 25326
 
  PERIOD ENDING   DUE DATE        # OF EMPLOYEES AT
                                     END OF PERIOD                                                                  PAYMENT

  MM   DD   YYYY  MM   DD   YYYY                                                                                   VOUCHER
                                                                                                            TOTAL 
                                                                                                                   
 ACCOUNT NUMBER ___________________________________________                                            REMITTANCE          .
                                                                                                      
 NAME_________________________________________________________ 

 ADDRESS______________________________________________________  

 _______________________________________________________________
 CITY                                                         STATE                   ZIP             B     4     2     2     0     1     6     0     1     W