West Virginia 
WV/COA                                                                                                                                State Tax 
Orig. 03-17                         Individual Change of Address                                                            Department

            ►Do not use this form for changing business aDDress

Individuals may use this form to notify the West Virginia State Tax Department of a change in address. To complete this form, provide the information 
requested. This form must be signed and dated, including spouse (if applicable). Incomplete AND illegible forms will not be processed. This form is 
intended for use by individuals. If you wish to change a business address, please register to use or logon to MyTaxes at mytaxes.wvtax.gov. Instructions 
for submitting address change for businesses may be found by accessing Help, Business/Tax Professional, Account/Names/Addresses section.

First Name                                  MI              Last Name                                  Last 4 digits of SSN or 8 Digit Account ID

First Name (SPOUSE, if applicable)          MI              Last Name (Spouse)                         Last 4 digits of SSN or 8 Digit Account ID

NEW Resident Address                                                                                         Unit/APT

City                                                        State     Zip/Postal Code                  County

NEW Mailing Address (If different from resident address)                                                     Unit/APT

City                                                        State     Zip/Postal Code                  County

FORMER Resident Address                                                                                      Unit/APT

City                                                        State     Zip/Postal Code                  County

FORMER Mailing Address (If different from resident address)                                                  Unit/APT

City                                                        State     Zip/Postal Code                  County

By signing below, you are authorizing the West Virginia State Tax Department to change this address and certify to the best of your knowledge and 
belief that this report is true.

            Signature                                                                                        Date
Primary 
Taxpayer             E-mail Address                                                                          Daytime Phone
                     The West Virginia State Tax Department may contact me using the following method (mark all that apply):
                                E-mail     YES      NO                       Phone     YES      NO Mail     YES      NO

            Spouse’s Signature                                                                               Date

Spouse               E-mail Address                                                                          Daytime Phone
                     The West Virginia State Tax Department may contact me using the following method (mark all that apply):
                                E-mail     YES      NO                       Phone     YES      NO Mail     YES      NO

Mail completed form to West Virginia State Tax Department, Personal Income Tax Unit, PO Box 2389, Charleston, WV 25328-2389