West Virginia Request for Statement of Good Standing

Request for Statement of Good Standing
Form GSR-01
GSR-01
Rev.09/2020

West Virginia
Request for Statement of Good Standing

West Virginia
State Tax
Department

Taxpayer Identification Number ______________________ Identification Type ___________________________________________
Name of Business/Individual___________________________________________________________________________
Location Address __________________________________________________________________________________
Mailing Address ____________________________ _______________________ _____________ ________________
Street

City

State

Zip

Purpose for request (check one):
 ABCA

 DMV

 DOH

 SOS

 Bank Loan

 Other (specify below)
_________________

I understand that in the event that this business is not in good standing with the Tax Department I will be notified in writing
as to what tax returns or tax payments are considered not filed or paid and who to contact with any questions regarding that
situation.
By signing this Request for Statement of Good Standing, I certify under penalty of perjury that I am the taxpayer or the
taxpayer’s authorized representative and am entitled to receive the result of this request.
If you are a CPA or Attorney completing this Request for Statement of Good Standing for a business of which you are not a
principle, a principle of the business must ALSO sign this request as the taxpayer.
If you are authorizing release of information for someone who is not a CPA or Attorney, this form must be notarized.
Taxpayer Signature

Title

Date

Print Name

Phone

E-mail

CPA/Attorney Signature

Title

Date

Print Name

Phone

E-mail

Signature of person other than taxpayer, CPA, or
attorney (Form must be notarized).

Title

Date

Print Name

Phone

E-mail

State of West Virginia
County of __________________________, to-wit,
This day appeared before me, the undersigned notary public ________________________________________, who
acknowledge under oath the signature above.
_________________________________________ Notary public
My commission expires: ___________________________

Send this request to:
West Virginia State Tax Department
ATTN: TPS – Support Unit
PO Box 885
Charleston, WV 25323-0885

____________________________

Phone Numbers:
(304) 558-3333
(800) 982-8297
Follow Prompts for
Statement of Good Standing Requests.

Date