Completion and timely submittal of this form to the West Virginia State Treasurer's Office will assure your compliance with West Virginia State law and will assist in the maintenance of a complete data base. West Virginia Code §12-6A-6(b) requires the issuer of any proposed State debt issue to give written notice of the proposed sale to the Treasurer no later than 30 days prior to the sale.
Additionally, please provide a copy of the preliminary official statement (or offering circular) with this form or when it becomes available.

Thank you for your cooperation.

 
Name of Issuer:
Proposed Issue Sale Date:
Type of Sale: Competitive    Negotiated
Principal to be Sold (expected): $
Is the Interest on the Debt Exempt from Taxation?
  Under State Law:    
No (taxable) Yes (tax-exempt)
  Under Federal Law:
No (taxable) Yes (tax-exempt)
If the issue is Federally tax-exempt, is interest a specific preference item for the purpose of alternative minimum tax? Yes No
Is any portion of the debt for refunding?
No
Yes, amount of this issue (including costs)
        which is for refunding of existing debt $
 
Type of Debt Instrument:
Please specify if "Other note", "Other bond", or "OTHER" was checked:
 

Sources of Repayment:
Select Multiple by holding down the "ctrl" key (cmd key on Macintosh)
If "Other" Please specify:
 

Purposes of Financing:
Select Multiple by holding down the "ctrl" key (cmd key on Macintosh)
 
Please specify type/name of project:
 
PARTIES INVOLVED
Bond Counsel:
Issuer Counsel:
Underwriter Counsel:
Disclosure Counsel:
Tax Counsel:
Local Counsel:
Trustee:
Financial Advisor:
Auditor:
Lead Underwriter:
 

or PURCHASER(S):

or PLACEMENT AGENT:
Name of individual (representing Bond Counsel, Issuer, Financial Advisor, or Lead Underwriter) who completed this form and may be contacted for information:
Name:
Firm/Agency:
Address:
e-Mail Address:
Phone:
Date of Completion:
Contact person at issuing agency, if different from above:
Name:
Title:
Address:
e-Mail Address:
Phone:
 
 
 
  Once this online form is processed it will be time  
stamped and emailed to the listed contact person.