Form 763-S - Virginia Special Nonresident Claim For Individual Income Tax Withheld
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1
2*VA763S114888*
763-S
2014
Virginia Special Nonresident Claim
For Individual Income Tax Withheld
First Name
MI
Last Name
Suffix
Your Social Security Number
Present Home Address (Number and Street, Including Apartment Number or Rural Route)
Spouse’s Social Security Number
City, Town or Post Office
State
ZIP Code
Amended Claim
I (we) authorize the Department of Taxation to discuss my (our) return with my (our) preparer.
Your Birthday
Date of Birth
-
-
Primary Taxpayer Deceased (Include Federal Form 1310 if
(MM-DD-YYYY)
applicable)
STEP I - Exemption Category
.
Review categories 1 - 4 below and enter the category number for which you are claiming an exemption
1
Commuter State Exemption: I declare that during the taxable year shown above I commuted on a
daily basis from my place of residence to work in Virginia. My only income from sources within Virginia
was from wages and salaries, which are subject to taxation by the state or district checked below. I
did not live in nor was I a domiciliary or legal resident of Virginia at any time.
Check One:
District of Columbia
Kentucky
2
Domiciliary State Exemption: I declare that during the taxable year shown above I was a domiciliary
or legal resident of the state checked below. My only income from sources within Virginia was from
wages and salaries, which are subject to taxation by the state checked below. I am not an actual
resident of Virginia and I did not maintain a place of abode in Virginia for a total of more than 183 days.
Check One:
Maryland
Pennsylvania
West Virginia
3
Military Spouse Exemption: Complete the back of this form first. I declare that for the entire portion
of the year I lived in Virginia I was married to a service member on active military duty who was in
Virginia pursuant to military orders. I have not taken any action to abandon my domicile in another
state or to become a domiciliary or legal resident of Virginia. To be exempt, you and your spouse
must have the same domiciliary or legal state of residency. Enter the 2 letter state abbreviation for:
3(a) Your domiciliary or legal state of residency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3(b) Your spouse’s domiciliary or legal state of residency for military payroll purposes . . . . .
4
Tax Withheld in Error by Employer: I declare that during the taxable year shown above I was not
a domiciliary or legal resident of Virginia at any time. I did not perform any services in Virginia and
the Virginia tax was erroneously withheld from salary and wages paid to me by my employer.
Enter the 2 letter state abbreviation for your domiciliary or legal state of residency . . . . . . . . . . . .
STEP II - Enter amount of Virginia Tax withheld requested to be refunded:
If amended, enter the full refund amount as it should have been reported
$
on the original return. You must provide copies of your withholding statements.
STEP III - Avoid delays: If you are a Resident of a State with an Individual Income Tax, attach a
complete copy of your State of Residence Income Tax Return and check this box.
If the Direct Deposit section below is not completed, your refund will be issued on a Debit Card.
Checking
Savings
DIRECT BANK DEPOSIT
Your Bank Routing Transit Number
Account Number
Domestic Accounts Only
No International Deposits
Due by May 1, 2015. Mail to the Department of Taxation, P.O. Box 1498, Richmond, Virginia 23218-1498.
Each spouse must complete a separate Form 763-S when both filers have Virginia income tax withheld.
I, the undersigned, do declare under penalties provided by law that this is a true, correct and complete return.
Please
Your Signature
Date
Your Phone
Office Use
X
(
)
Sign Here
Preparer’s
Preparer’s Name
Date
Preparer’s Phone Number
X
Use Only
Firm’s Name (or Yours if Self-employed) and Address
Preparer’s FEIN/PTIN/SSN
Code
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