SCHEDULE 
   DSV-1                TAX CREDIT FOR DONATION OR SALE OF VEHICLE                                                                                        West Virginia 
                   Through Charitable Organization That Provides A ffordable Transportation to Low-Income Workers                                       State Tax Department
   REV09-2020
To claim credit, file this with your Income Tax return against which the Credit is claimed. All Sections must be completed. 
Qualified Charitable Organization must complete Section B.  
                                       SECTION A: DONOR OR SELLER IDENTIFICATION 
1  FEIN OR SSN                             WV TAX ID                                                    TAX PERIOD ENDING 
                                                                                                        MM DD YYYY
   NAME OF TAXPAYER (DONOR OR SELLER )
2
   PHYSICAL ADDRESS OF TAXPAYER OR SELLER

3  CITY                                                                                                 STATE                                ZIP

                                                                 VEHICLE INFORMATION
4  MAKE                                    MODEL                                                        YEAR
5  VEHICLE IDENTIFICATION NUMBER (VIN) 
6  ESTIMATED FAIR MARKET VALUE OF THE VEHICLE
                                                   DONOR OR SELLER’S CERTIFICATION
                                                                           Check only one that applies
   DONOR CERTIFICATION : By signing below, I certify that I have donated the below-referenced vehicle to the quali fied charitable organization identi fied herein for no consideration
   SELLER CERTIFICATION : By signing below, the seller of the below vehicle certi fies that, having made a diligent search, it  finds that the vehicle:
                                     • Has passed a West Virginia safety inspection;
7                                    • Has not been reported as stolen and not recovered;
                                     • Has informed the program participant whether the vehicle is subject to any unperformed safety recalls;
                                     • Has not been reported as a total loss as the result of an accident;
                                     • Has not been  flood-damaged;
                                     • Has not been junked or salvaged;
                                         and that the vehicle is suitable to provide safe and reliable transport for commuting to employment.

               SIGNATURE OF DONOR OR SELLER                                  NAME OF DONOR SELLER (PRINT OR TYPE)                            DATE
                             SECTION B: CHARITABLE ORGANIZATION INFORMATION
8  NAME OF QUALIFIED CHARITABLE ORGANIZATION:
   ADDRESS OF QUALIFIED CHARITABLE ORGANIZATION

9  CITY                                                                                                 STATE                                ZIP

10 WV TAX ID OF QUALIFIED CHARITABLE ORGANIZATION
                                                          PROGRAM VALUE AND CREDIT
11 REDUCED SALES PRICE (LICENSED DEALERS ONLY)

12 DETERMINED PROGRAM VALUE OF VEHICLE
13 VALUE OF DEALER PRICE REDUCTION 
   (SUBTRACT REDUCED SALE PRICE FROM PROGRAM VALUE )
   MAXIMUM AMOUNT OF CREDIT AUTHORIZED - MAY NOT EXCEED MAXIMUM CREDIT OF $2,000
14 DONORS:   50% OF LINE 12 PROGRAM VALUE OR 
   DEALERS : 50% OF LINE 13 DEALER PRICE REDUCTION
                             CERTIFICATION OF QUALIFIED CHARITABLE ORGANIZATION
   THE  ABOVE NAMED CHARITABLE ORGANIZATION HEREBY CERTIFIES THAT THE TAXPAYER NAMED HEREIN IS ELIGIBLE FOR THE CREDIT  ALLOWED UNDER  
   W. VA. CODE §11-13FF-1, ET SEQ., IN AN AMOUNT NOT TO EXCEED THE AMOUNT LISTED ON LINE 14 FOR THE SALE OR DONATION OF THE VEHICLE IDENTIFIED BELOW.
   BY SIGNING BELOW, THE AUTHORIZED REPRESENTATIVE OF THE QUALIFIED CHARITABLE ORGANIZATION NAMED BELOW CERTIFIES THAT THE ORGANIZATION HAS 
   GIVEN NO CONSIDERATION IN EXCHANGE FOR THE DONATED VEHICLE, OR, IN THE CASE OF A SOLD VEHICLE, THAT THE ORGANIZATION HAS NOT RECEIVED ANY 
                                                       CONSIDERATION FROM THE SELLER OF THE VEHICLE.  
15

        AUTHORIZED SIGNATURE OF CERTIFYING QUALIFIED CHARITABLE ORGANIZATION                          DATE OF DONATION

        Authorized representative of the quali fied charitable organization (PRINT OR TYPE)            DATE

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