Citizen Consent Form - West Virginia Department Of Revenue
ADVERTISEMENT
1CITIZEN CONSENT FORM
The West Virginia Department of Revenue is seeking your consent to process your personal
information. The Department needs to obtain your consent in accordance with the West Virginia
Executive Branch Privacy Policy (WVEB-P102) effective August 1, 2009.
1. The Department 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 Department services.
•
Information related to your use of all Department of Revenue Agencies and the services
offered at each of the Department of Revenue Agencies.
•
Your name, address, and social security number.
•
Your tax identification number.
2. The Department will process this information for the following purposes such as but not limited to:
•
To search Department of Revenue records in order to access your past and current
business activity with the Department of Revenue and to assist you.
•
To search Department of Revenue Agencies’ records in order to access your past and
current business activity with such agencies and to assist you.
•
To allow the Division of Personnel, Department of Revenue and its agencies conduct a
background check for employment in accordance with laws that apply to sensitive
security positions.
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 Department of Revenue
Attention: Privacy Officer
State Capitol
Building 1, Room W-300
1900 Kanawha Boulevard East
Charleston, West Virginia 25305
(304) 558-0211 (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 Department of Revenue
March 5, 2009
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial