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Form Mitc-A - Application For West Virginia Manufacturing Investment Tax Credit For Investments Placed In Service On Or After January 1, 2003 Page 2

Jobs

4. Employment:

Payroll

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 11275

Charleston, WV 25339-1275

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)

Schedule MITC-A Page 2 of 2

REV. 12-11

Form Mitc-A - Application For West Virginia Manufacturing Investment Tax Credit For Investments Placed In Service On Or After January 1, 2003 Page 2