Form Wv-Ari-001 - Authorization To Release Information - 2014
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West Virginia
WV-ARI-001
Authorization to Release Information
State Tax
Rev. 7/14
Department
Name of Taxpayer _____________________________________________________________ Date _______________
Address _____________________________________________ Daytime Telephone ____________________________
City _________________________________________________ State ____________ Zip Code __________________
West Virginia Identification, SSN, FEIN, or Other __________________________________________________________
The above named taxpayer does hereby waive the confidentiality provisions of West Virginia Code §11-10-5d and/or
§11-1A-23 to the following extent:
1. Persons to whom information may be released:
Name _______________________________________________ Capacity ___________________________________
Address ___________________________________________________ Daytime Telephone ______________________
City, _________________________________________________ State __________________ Zip Code ____________
2. Effective period of this waiver
Authorization terminates ______________________________________
month
day
year
Until my liability for the delinquent tax or taxes checked in paragraph 3, below, is satisfied.
Other (explain) __________________________________________________________________________________
_________________________________________________________________________________________________
3. Taxes and/or credits to which this waiver applies:
WV Code
WV Code
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Beer Barrel Tax
11-16
Minimum Severance Tax on Coal
11-12B
Business and Occupation Tax
11-13
Motor Carrier Road Tax
11-14A
Business Franchise Tax
11-23
Personal Income Tax
11-21
Business Registration Tax
11-12
Property Taxes
Charitable Raffle Boards & Games
47-23
Severance Tax
11-13A
Consumer Sales and Service Tax
11-15
Solid Waste Fee
20-5F
Corporate License Tax
11-12C
Soft Drink Tax
11-19
Strategic Research and Development Tax Credit
Corporate Net Income Tax
11-24
11-13R
Economic Opportunity Tax Credit
11-13Q
Telecommunications Tax
11-13B
Employers Withholding Tax
11-10
Tobacco Products Excise Tax
11-17
Estate Tax
11-11
Use Tax
11-15A
Gasoline & Special Fuel Excise Tax
11-14
Wine Liter Tax
60-8
Health Care Provider Taxes
11-27
All of the above applicable to the taxpayer
IFTA
11-14B
Other Taxes (as listed below)
Manufacturing Investment Tax Credit
11-13S
4. Information to be released (describe specifically):
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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