STATE OF WEST VIRGINIA 
State Tax Department, Tax Account Administration Div
P.O. Box 425
Charleston, WV 25322-0425

            ADDITIONAL TAX ON THE SEVERANCE OF NATURAL RESOURCES ESTIMATE
WV/SEV-400V
rtL040 v14-Web

Taxpayers required to file electronically will no longer receive returns for the tax types subject to the mandatory requirement
                           by mail.  Please visit www.wvtax.gov for additional information.

                           MAKE CHECK PAYBLE AND MAIL TO:  WEST VIRGINIA STATE TAX DEPARTMENT
                                                    Tax Account Administration Div
                                                   P.O. Box 425, Charleston, WV  25322-0425
                                                   FOR ASSISTANCE CALL   TOLL FREE
                                                   For more information visit our web site at:
                                                   File online at https://mytaxes.wvtax.gov

                          PLEASE CUT HERE  USE BLUE OR BLACK INK TO COMPLETE VOUCHER  DO NOT WRITE IN BARCODE AREA

WV/SEV-400V rtL040 v14-Web
                                                   ADDITIONAL TAX ON THE SEVERANCE
                                                   OF NATURAL RESOURCES ESTIMATE
              Account ID #                                                                  Period Ending:                  Due Date:
                                                                                                                                     TAX DUE
                          RESOURCE                                                          TAXABLE AMOUNT           RATE   (MULTIPLY AMOUNT BY RATE)
              1. COAL-tons for the period                                                                  . 00      0.56                   .
              2. NATURAL GAS-mcf for the period                                                            . 00      0.047                  .
              3. COALBED METHANE-mcf for the period                                                        . 00      0.047                  .
              4. TIMBER-gross $ for the period                                                             .         0.0278                 .
              5. Total Tax (Add lines 1 through 4)                                                                                          .

              Name

              Address
                                                                                                           SIGNATURE                        DATE
              City                                                 State                 Zip