WEST VIRGINIA                                                      West Virginia 
  GSR-01                                                                                                                Tax Division
  REV 05/2023                REQUEST FOR LETTER OF GOOD STANDING

                                                  TAXPAYER IDENTIFICATION
TAXPAYER                                                                       IDENTIFICATION 
IDENTIFICATION                                                                 TYPE
NUMBER
BUSINESS NAME
LOCATION 
ADDRESS
MAILING 
ADDRESS
               Street                                                          City                      State    Zip

                                          PURPOSE FOR REQUEST (CHECK ONE):
  ABCA         DMV       DOH        OMC     SOS             AGRICULTURE    BANK LOAN          OTHER (SPECIFY) 

                                                            SIGNATURE
I understand that in the event that this business is not in good standing with the Tax Department I will be noti fied 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 Letter of Good Standing, I certify under penalty of perjury that I am the taxpayer or the taxpayer’s autho-
rized representative and am entitled to receive the result of this request.
If you are a CPA or Attorney completing this Request for Letter 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.

SIGNATURE OF TAXPAYER                                            TITLE                              DATE

NAME OF TAXPAYER (PRINT OR TYPE)                                 PHONE                              EMAIL

SIGNATURE OF CPA OR ATTORNEY                                     TITLE                              DATE

NAME OF CPA OR ATTORNEY(PRINT OR TYPE)                           PHONE                              EMAIL

SIGNATURE OF PERSON OTHER THAN TAXPAYER, CPA, OR                 TITLE                              DATE
ATTORNEY (FORM MUST BE NOTARIZED).

NAME OF PERSON OTHER THAN TAXPAYER, CPA, OR                      PHONE                              EMAIL
ATTORNEY(PRINT OR TYPE) 
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

                                                                                              ____________________________ DATE
MY COMMISSION EXPIRES: ___________________________

               SEND THIS REQUEST TO:                                    PHONE NUMBERS:
               West Virginia Tax Division                               (304) 558-3333
               ATTN: TPS – Support Unit                                 (800) 982-8297
               PO Box 885                                               Follow Prompts for
               Charleston, WV 25323-0885                                Letter of Good Standing Requests.