Citizen Consent Form - West Virginia Office Of Tax Appeals

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CITIZEN CONSENT FORM
The West Virginia Office of Tax Appeals is seeking your consent to process your personal
information. The Agency needs to obtain your consent in accordance with the West Virginia
Executive Branch Privacy Policy (WVEB-P102) effective August 1, 2009.
1. This Agency is requesting your consent to process the following types of personal information such as
but not limited to:
Your contact information and information related to your use of Agency services.
Information related to your use of the State Tax Commissioner’s Office.
Your name, address, and social security number.
Your tax identification number.
2. The Agency will process this information for the following purposes such as but not limited to:
To search Agency records and request those of the State Tax Commissioner’s Office in
order to access your past and current business activity with the Department of Revenue
and to assist you.
3. Your personal information will at times be subject to our internal Privacy Policies and Security Policies.
Your personal information will be accessed only by persons that are specifically authorized and bound by
confidentiality obligations.
4. You may revoke your consent at any time. Please note if you revoke your consent, you may be unable to
receive certain benefits. Additionally, we will continue to process your personal information as required by
law.
5. If you have any questions on sensitive information pertaining to you being processed by us, or if you
would like to revoke your consent, please contact:
West Virginia Office of Tax Appeals
Attention: Executive Director/Privacy Officer
1012 Kanawha Boulevard, East
Suite 300
Charleston, West Virginia 25301
(304) 558-1666 (telephone)
ACKNOWLEDGEMENT AND CONSENT
I read and understood this notice. I agree that my personal information may be processed for the purposes
specified above. I have been provided with a hard copy of this notice.
Name: ___________________________________________________ Date: _______________________
Signature: ________________________________________________________________
West Virginia Office of Tax Appeals
April 20, 2009

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