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                Application for West Virginia Manufacturing Investment Tax Credit 
MITC-A
REV 3-15        for Investments Placed in Service On or After January 1, 2003

Name                                            Identification Number

Business Name                                   Tax Year
                                                _______________, ____________ to _______________, ____________
Street Address

City, Town, or Post Office                      State                                                     Zip Code

Application is hereby made to the Tax Commissioner of West Virginia for allowance of Manufacturing Investment Tax Credit with respect to qualified 
manufacturing investment property placed in service or use during Applicant’s tax year ending:
                                                                                                            /                 /
                                                                                              MM DD                            YYYY
**Manufacturers must complete items 1 through 5 and the certification. Businesses whose primary NAICS code is 211112 must complete 
items 1 through 6 and the certification.**
1.  Investment Purpose (Check only 1)
  Industrial Expansion
  Industrial Revitalization
  Both Industrial Expansion and Revitalization
2.  Business Activity in West Virginia:
a) North American Industry Classification System Code (NAICS): ___________________________________
b) Narrative Description of Business Activity in West Virginia:

3a.  Investment                                 Total Investment                              Qualified Investment

Year________________________              Amount $___________________                         $___________________________

3b. Location(s) of Investment in West Virginia _________________________________________________________ 

3c. General Description of Qualified Investment (Narrative):

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4.  Employment:                                                            Payroll          Jobs
    a) Total WV payroll and number of jobs prior to investment:
    b) Total WV payroll and number of jobs this year:

5.  Benefits:

a) Percentage of employes covered under health plans:                                      %

b) Average annual health plan benefit costs per employee:

c) Percentage of employees covered under retirement plan:                                  %

d) Average annual retirement benefit cost per employee:
                             **Businesses whose primary NAICS Code is 211112
6.  In application for the Manufacturing Investment Tax Credit, it is affirmed that the applicant is in compliance with the 
    additional Manufacturing Investment Tax Credit requirements for businesses whose primary North American Industry 
    Classification System (NAICS) Code is 211112 (The additional requirements are prescribed in WV Code §11-13S-4(e) 
    and are enumerated in the instructions).

                                            Affirmation:        In compliance
                                                                Not in compliance

Under penalties of perjury, I declare that I have examined this credit claim form (including accompanying schedules and 
statements) and to the best of my knowledge 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

Please return the completed application to:
    West Virginia State Tax Department
    PO Box 2991
    Charleston, WV 25330-2991

If you have any questions or need further information regarding this application, telephone (304) 558-3333 or toll free to 
1-800-WVA-TAXS (1-800-982-8297)

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                                                      APPLICATION FOR WEST VIRGINIA MANUFACTURING 

                                                     INVESTMENT TAX CREDIT FOR INVESTMENTS PLACED IN 

                                                        SERVICE ON OR AFTER JANUARY 1, 2003

                                                                          Information and Instructions

                                                      HE Manufacturing Investment Tax Credit (MITC)      investment. (Check only one block.)
                                                      is available to a manufacturer making a qualifi ed 
                                                      investment (on or after January 1, 2003) for                         a.  The Taxpayer for purposes of industrial expansion 
                                                      purposes of industrial expansion or revitalization                                                                                                 places qualifi ed investment property in service or use. 
Tof an industrial facility within West Virginia. Qualifi ed 
                                                                                                                           b. The Taxpayer for purposes of industrial revitalization 
businesses include only those engaged in the activity of 
                                                                                                                                                                                                         places qualifi ed investment property in service or use. 
manufacturing within West Virginia. Manufacturing is 
defi ned  as  any  business  activity  classifi ed  as  having  a                                                            c.  The Taxpayer for purposes of both industrial expansion 
sector identifi er, consisting of the fi rst two digits of the six-                                                                                                                                        and revitalization places qualifi ed property in service 
digit North American Industry Classifi cation System code                                                                                                                                                 or use. 
number, of thirty-one, thirty-two or thirty-three or the six 
digit North American Industry Classifi cation System Code                                                 tttttteeeeeem m m m m m
                                                                                                         IIIIII                                                                                           Business Activity in West Virginia: 
Number 211112.                                                                                                             2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
                                                                                                                                                                                                          
The Manufacturing Investment Tax Credit is not available 
                                                                                                                                                              a.  Enter the North American Industry Classifi cation 
to businesses engaged in the activity of electric power 
                                                                                                                                                                                                         System Code that most closely describes your business 
generation. Qualifi ed investment by businesses engaged 
                                                                                                                                                                                                         activity in West Virginia. 
in the activity of electric power generation qualify for 
another investment tax credit, the Industrial Expansion and                                                                b. Describe the industrial expansion or industrial 
Revitalization Credit.                                                                                                                                                                                   revitalization activity in West Virginia that is associated 
Industrial expansion is defi ned as capital investment in a                                                                                                                                               with your new investment (e.g., construction of a new 
new or expanded industrial facility in this State. Industrial                                                                                                                                            reconstituted wood product manufacturing plant).
revitalization  or  revitalization  is  defi ned  as  capital                                                         mmmmmm
investment in an industrial facility located in this State to                                            ttttttIIIIIIeeeeee
                                                                                                                                                                                                          Investment: Enter the year investment is placed 
                                                                                                                     3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a3a
replace or modernize buildings, equipment, machinery and                                                                                                                                                  into service or use in the fi rst column, the total 
                                                                                                                                                                                                          
other tangible personal property used in connection with                                                 dollar amount of investment placed into service or use 
the operation of the facility in an industrial business of the                                           in the second column and the dollar amount of qualifi ed 
Taxpayer, including the acquisition of any real property                                                 investment placed into service or use in the third column. 
necessary to the industrial revitalization. Industrial business                                          Qualifi ed  Investment  is  determined  according  to  the 
or industrial Taxpayer is defi ned as any Taxpayer who is                                                 following useful life (straight line depreciation): 
primarily engaged in a manufacturing business. 
                                                                                                                                                                                                                 Useful Life
By Law, no credit may be allowed or applied for any qualifi ed                                                                                                                                            At Least But Less Than     Percent Qualifi ed
investment property placed in service until the person 
                                                                                                                                                                                                         0   —    4 years           0
asserting a claim for the credit makes writt en application 
                                                                                                                                                                                                         4   —    6 years           33-1/3
to the Tax Commissioner.  Failure to timely apply for credit 
will result in forfeiture of 50% of the annual credit allowance                                                                                                                                          6   —    8 years           66-2/3
otherwise available under this requirement. Form MITC-A                                                                                                       8 or more years                                                       100
is designed to be a general application form for taxpayers                                                           m m m m m m
wishing to claim credit based upon investments placed into                                               ttttttIIIIIIeeeeee
                                                                                                                                                                                                          Enter  the  location(s)  of  the  qualifi ed  investment 
                                                                                                                     3b3b3b3b3b3b3b3b3b3b3b3b3b3b3b3b3b3b3b3b3b3b3b3b3b3b3b3b3b3b
use or service on or after January 1, 2003. The timely fi ling                                                                                                                                             property (i.e. Main Street, Weston, or 12 miles north 
                                                                                                                                                                                                          
of this application is a condition precedent to claiming tax                                             of Pipestem at the Intersection of State Route 3 and State 
credits. This application must be fi led annually no later                                                Route 20). 
than the due date of the taxpayer’s West Virginia income                                                             m m m m m m
tax return including any legally granted extension of time                                               ttttttIIIIIIeeeeee
                                                                                                                                                                                                          Provide  a  general  description  of  the  qualifi ed 
for fi ling such returns.                                                                                             3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c3c
                                                                                                                                                                                                          investment property in the space provided (i.e. 
                                                                                                                                                                                                          
                                                                                                         $100,000 to be invested in buildings, $500,000 to be invested 
                                                                                                         in machinery and equipment, etc.) 
            mmmmmm                                    INSTRUCTIONS T OFORM MITC-A 
ttttttIIIIIIeeeeee
                                                      Investment Purpose: Place a check mark in the 
                  1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
                                                      block next to the applicable purpose of your 
                                                      
MITC-A Rev. 3-15                                                                                                                                                                                                                              Page 1 



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ttttttIIIIIIeeeeeem m m m m m
                                                   Employment:                                               employees for said construction from the local labor 
                  4 4 4 4 4 4 4 4 4 4 4 4
                                                                                                             market, to be rounded off , with at least two employees 
                                               a.  Enter your total West Virginia payroll and number         from outside the local labor market permissible for each 
                                               of jobs att ributed to that payroll for the prior year (i.e., employer per project, “the local labor market” being 
                                               twelve-month period) before the placement of this             defi ned as every county in West Virginia and any count 
                                               year’s qualifi ed investment subject to Manufacturing          outside of West Virginia if any portion of that county is 
                                               Investment Tax Credit into service or use.                    within fi fty miles of the border of West Virginia.
                  b. Enter your total West Virginia payroll and number of                                    (2) Any person or entity unable to employ the minimum 
                                               jobs for the current year.                                    number of employees from the local labor market shall 
ttttttIIIIIIeeeeeem m m m m m                                                                                inform the nearest offi  ce of the bureau of employment 
                                                   Benefi ts:                                                 programs’ division of employment services of the 
                  5 5 5 5 5 5 5 5 5 5 5 5                                                                    number of qualifi ed employees needed and provide a 
                                               a.  Enter the percentage of your employees covered            job description of the positions to be lled.
                                               under your sponsored health insurance plan.                   (3) If, within three business days following the placing of 
                  b. Enter  the  average  annual  cost  of  your  employer-                                  a job order, the division is unable to refer any qualifi ed 
                                               provided health insurance benefi ts (i.e., benefi t costs       job applicants to the person or entity engaged in said 
                                               divided by number of covered employees).                      construction  or  refers  less  qualifi ed  job  applicants 
                                                                                                             than the number requested, then the division shall 
                  c.  Enter the percentage of your employees covered under                                   issue a waiver to the person or entity engaged in said 
                                               your retirement plan.                                         construction to fi ll any positions covered by the waiver 
                                                                                                             from outside the local labor market. The waiver shall be 
                  d. Enter  the  average  annual  retirement  benefi t                                        either oral or in writing and shall be issued within the 
                                               contribution cost per covered employee.                       prescribed three days. A waiver certifi cate shall be sent 
ttttttIIIIIIeeeeeemmmmmm                                                                                     to the person or entity engaged in said construction for 
                                                   Additional Requirements for businesses Whose              its permanent project records.
                  6 6 6 6 6 6 6 6 6 6 6 6 6 6 6
                                                   Primary NAICS Code is 211112.
                                                                                                             The  timely  fi ling  of  this  application  coincides  with 
Check the appropriate box to affi  rm compliance with the                                                      the authorization for the Applicant to begin claiming 
provisions of WV Code §11-13S-4(e). That section of the                                                      Manufacturing Investment Tax Credit benefi ts.  Such fi ling 
code is copied below:                                                                                        of the application will not bar or otherwise prevent the Tax 
WV Code §11-13S-4(e)                                                                                         Commissioner from auditing or examining Applicant’s 
                                                                                                             books and records for compliance with the Manufacturing 
                  (1) Any person or entity undertaking any construction                                      Investment Tax Credit law and regulations. 
                  related to any business activity included within North 
                  American Industrial Code six digit number 211112, the                                      This  application  must  be  signed  by  an  offi  cer  of  the 
                  value of which is an amount equal to or greater than                                       company to be valid. 
                  $500,000,  shall  hire  at  least  seventy-fi ve  percent  of 

MITC-A Rev. 3-15                                                                                                                                           Page 2 






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