GSR-02
Rev. 01/2020
WEST VIRGINIA REQUEST FOR
STATEMENT OF GOOD STANDING FOR INDIVIDUALS
FOR O
FFICE OF MEDICAL CANNABIS
West Virginia
State Tax
Department
Businesses should request for good standing using GSR-01.
Social Security Number _____________________________
Individual Name (First) _________________________________(Last) ________________________________________
Mailing Address ____________________________ _______________________ _____________ ________________
Street City State Zip
Medical Cannabis Applicant Business Name _____________________________________________________________
I understand that in the event that I am not in good standing with the Tax Department I will be notified in writing as to whom 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 individual named above and am entitled to receive the result of this request.
Taxpayer Signature Title Date
Phone
E-mail
Print Name
__________________________________________ _______________________ _____________ ________________
Street City State Zip
If requesting information be sent to your authorized representative, please include their name and bar number or CPA
license number.
Attorney/CPA Name Bar Number/CPA License Number
If requesting information be sent to someone other than an attorney or CPA, this form must be notarized.
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: ___________________________
I would like the response sent via (check only one):
Send this request to: Phone Number:
West Virginia State Tax Department
ATTN: TPS – Administrative Support
PO Box 885
Charleston, WV 25323-0885
tpssupport@wv.gov
(304) 558-3333
E-mail, enter the e-mail address:_________________________________________________________________
Mail to the address listed below:
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