Form Gsr-01 - Request Of Statement Of Good Standing - State Tax Department - West Virginia
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1STATE OF WEST VIRGINIA
gsr-oi
Department of Revenue
State Tax Department
Joe Manchin ID
Craig A. Griffith
Govenor
Acting State Tax Commissioner
Request for Statement of Good Standing
Taxpayer Identification number
Complete business name
Business location
Is business a (check one)
Partnership
Sole Ownership
Corporatlon/LLC
If none of these apply, list type of business here
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 ami who to contactwith any
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 isnota CPA or Attorney, this form must be notarized.
Taxpayer signature
Title
Date
Print Name
Phone:
CPA/Attomey signature
Title
Date
Print Name
Phone:
Person other than
taxpayer, CPA or
Attorney signature
' .
(tan nut btnottftnd)
Title
Date
Print Name
Phone:
State of West Virginia,
Countv of
. to-wil
This day appeared before me, the undersigned notary public
acknowledge under oath the signature above.
My commission expires:
.who
Notary public
Date
If you wouM Oka the response faxed to you. enter fax number including area code
Send this request to:
West Vnginla State Tax Department
Administrative Support Una. 1001 Lee Street East. Charleston. WV 25301
Fax 004)558-8643
Phone: (304) 668-0678; (304) 5584618; (304) 558-6895; (304) 558-1114; (304) 558-8610; or (304) 558-C659
Revised 4/10
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Parent category: Financial