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

    Name

    Address                                                                                               Account #:

    City                                                            State                 Zip
                                                                 ANNUAL RETURN
WV/SEV-401V    ADDITIONAL TAX ON THE SEVERANCE OF NATURAL RESOURCES
rtL130 v.9-Web

Period Ending:                              Due Date:                                        Extension Date:
                                                                                                            M    M  D D            Y Y Y  Y
    Check if:  CONSOLIDATED                 SEPARATE                                              FINAL             AMENDED

               RESOURCE                                          TAXABLE AMOUNT                             RATE                   TAX DUE
1. COAL - Tons for the Year                                                                  . 00         0.56                            .
2. NATURAL GAS - mcf for the Year                                                            . 00         0.047                           .
3. COALBED METHANE - mcf for the Year                                                        . 00         0.047                           .
4. TIMBER - Gross $ for the Year                                                             .            0.0278                          .
5. Total Tax (Add lines 1 through 4)                                                                                                      .

6. Payments for the Period Covered by this Return and any Credit from Prior Years (Attach Credit Letter)                                  .
7. Balance of Tax Due (Line 5 minus Line 6) If Line 6 is greater than Line 5, enter 0 and skip to line 12                                 .
8. NON-WAIVABLE INTEREST                                                                                                                  .
9. ADDITIONS TO TAX                                                                                                                       .
10. PENALTY FOR UNDERPAYMENT OF ESTIMATED TAX                                                                                             .
11. TOTAL TAX AND LATE FILING CHARGES DUE (Add Lines 7 through 10)                                                                        .
12. Overpayment Amount (Line 6 minus Line 5) If Line 5 is greater than Line 6, enter 0                                                    .
13. Amount of Line 12 to be Credited to Next Year's Tax                                                                                   .
14. Amount of Line 12 to be Refunded (Line 12 minus Line 13)                                                                              .
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)

(Signature of preparer other than taxpayer) (Address)                                             (Date)

              MAIL TO:  WEST VIRGINIA STATE TAX DEPARTMENT
                        Tax Account Administration Div
                        P.O. Box 425, Charleston, WV  25322-0425
    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                                            G     0     4     2     0     0     8     0     1     W