West Virginia 
                        West Virginia Nonresident Income Tax Agreement
NRW-4                                                                                                                                    State Tax 
REV. 02/2021                                              Read Instructions on Reverse Side                                              Department

                                                                         Part I
  ORGANIZATION NAME AND MAILING ADDRESS                                            NONRESIDENT NAME AND MAILING ADDRESS
Name (please type or print)                                                  Name (please type or print)

Post O  ffice or Street Address                                                Post O  ffice or Street Address

City/Town                         State         Zip Code                     City/Town                        State            Zip Code

          West Virginia                               Federal                   Social Security Number or Federal                Spouse’s
     Identi fication Number                   Identi fication Number                    Identi fication Number              Social Security Number

Type of Organization: (check only one)                                       Type of Nonresident:
    Partnership         S Corporation          Estate                             Individual         Corporation        Partnership
    Trust               Limited Liability Company                            Nonresident’s Taxable Year:
Taxable Year of Organiation:                                                     Calender Year
    Calender Year                                                                Fiscal Year Ending ________________________________________
    Fiscal Year Ending ____________________________                          State of Residence or Commercial Domicile:_______________________
State of Commercial Domicile: ______________________

Internal Revenue Service center where organization’s federal return          Internal Revenue Service center where nonresident’s federal return is 
is filed:                                                                    fi led:
City____________________________________  State______________                City____________________________________ State_______________

                                                                         Part II
I declare that the above-named Distributee is a nonresident of West Virginia and that the nonresident Distributee hereby agrees to timely   le Westfi
Virginia Income Tax Returns (Form IT-140, CIT-120, or PTE-100) and pay any income tax due; that the Distributee will include in that return the portion 
of the above-named Organization’s West Virginia income or gain attributable to the nonresident Distributee’s interest in such Organization for the 
taxable year of the Distributee during which this Form is   ledfiwith the Organization and for each succeeding taxable year for which the Distributee 
receives actual or deemed distributions of West Virginia source income or gain; and that this Agreement remains in e ffect until it is revoked by either the 
Distributee or the Tax Commissioner.
SIGN
HERE
          (Signature of Nonresident Partner, Shareholder, or Bene ficiary, or of an Authorized Corporate O  fficer)

          (Print Name Signed Above

          (Mailing Address if Di fferent from above)                                                                        (Date)
                                                                         Part III
                           NOTICE OF REVOCATION OF NONRESIDENT INCOME TAX AGREEMENT
                                             WARNING: COMPLETE ONLY IF REVOKING AGREEMENT
Notice is hereby given that the West Virginia Nonresident Income Tax Agreement (Form WV/NRW-4) previously executed by or on behalf of the 
above-named Nonresident is revoked for taxable years of the above-name Organization (Pass-through entity) that begins after today’s date.
SIGN
HERE
          (Signature of Nonresident Partner, Shareholder, or Bene ficiary, or of an Authorized Corporate O  fficer)

          (Print Named Signed Above)

          (Mailing Address if Di fferent from Above)                                                                        (Date)

Form NRW-4                                             West Virginia State Tax Department                                                        Page 1

                            WEST VIRGINIA NONRESIDENT INCOME TAX AGREEMENT

                                                       INSTRUCTIONS

Who May File: Any nonresident individual, corporation, or partnership who has West Virginia source income derived from a 
partnership, S Corporation, estate, trust, or limited liability company (“organization”) who desires to not have West Virginia 
income tax withheld by that organization as provided in West Virginia Code § 11-21-71a, must complete a West Virginia 
Nonresident Income Tax Agreement (Form WV/NRW-4) and timely  fi           le it with the organization. A corporation is a nonresident 
if its commercial domicile is located in another state.

When and Where to File:    This form must be completed and   ledfi     with the organization on or before the last day of the 
organization’s taxable year. If the distributee receives West Virginia source income from more than one such organization, 
a separate form WV/NRW-4 must be  filed with each organization in order to avoid withholding by that organization. The 
organization may copy this form or use a facsimile to distribute as follows: (1) one copy to be   lefiwith the organization’s 
West Virginia income tax return, (2) one copy to be retained by the pass-through entity, and (3) one copy of the nonresident 
distributee.

West Virginia Income Tax Withholding for Nonresidents: Every Organization distributing West Virginia source income to 
a nonresident distributee is required to withhold West Virginia income tax on the amount thereof distributed to Nonresident 
Distributee unless the nonresident distributree tile  files this form the tax return   lefifor the taxable year of its receipt. The 
withholding tax rate is 6.5% of distributions of West Virginia source income (whether actual or deemed distributions). The 
amount of tax withheld and remitted by the organization is allowed as a credit against the distributee’s West Virginia income 
tax liability for that taxable year.

Nonresident Agreement: Once this agreement is executed, it must be  fi        led with the organization to avoid having withholding 
tax deducted from further distributions (actual or deemed). This agreement  fi    rst applies to the taxable year of the organization 
during which the organization receives a properly executed agreement from the nonresident distributee.

Duration of Agreement:    Once this agreement is  filed with the organization, it remains in e  ectff   until it is revoked by the 
nonresident distributee, or by the Tax Commissioner.

Revocation:

1.   A nonresident distributee may revoke this agreement by completing this form and   lingfi          it with the organization 
through which it receives source income. Revocation applies prospectively, meaning that it  first applies to taxable years of 
the organization which begin after revocation is  filed with that organization.

2.   The Tax Commissioner may revoke this agreement if the nonresident distributee fails to  fi           le a West Virginia income 
tax return (IT-140, PTE-100, or CIT-120) for more than 60 days after the due date of the return (determined by including any 
authorized extensions(s) of time for  filing such return, or to timely pay West Virginia income tax for any taxable year covered 
by this agreement.

Form NRW-4                                  West Virginia State Tax Department                                            Page 2