W. Va. Code R. § 110-13FF-7
[name of qualified 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 $___________________ for the sale or donation of the vehicle identified below.
Address of qualified charitable organization:
_____________________________________________________
Taxpayer Identification Number of qualified charitable organization:
_________________________
Vehicle make, model, and year:
______________________________________________________
Vehicle Identification Number (VIN):
______________________________________________________
Name of Taxpayer or Seller:
______________________________________________________
Physical address of Taxpayer or Seller:
______________________________________________________
Taxpayer identification number:
______________________________________________________
Program value of vehicle:
$_____________________________________________________
Maximum amount of credit authorized:
$_____________________________________________________
Donor's Certification:
By signing below, I certify that I have donated the above-referenced vehicle to the qualified charitable organization identified herein for no consideration.
Seller's Certification
By signing below, the seller of the above vehicle certifies that, having made a diligent search, it finds that the vehicle:
* Has passed a West Virginia safety inspection;
* 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.
Certification of qualified charitable organization:
By signing below, the authorized representative of the qualified charitable organization named above 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. The date of donation is ________________.
Signature of donor or seller:
_________________________________________________________
Date of signature:
_________________________________________________________
Authorized signature of certifying Qualified Charitable Organization:
_________________________________________________________
Date of signature:
_________________________________________________________
W. Va. Code R. § 110-13FF-7