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INFORMATION TO SUPPORT CLAIM FOR SUBSIDY OF 100% OF
INCOME TAXES PAID ON VIRGIN ISLANDS LOTTERY WINNINGS
TAXABLE
INCLUDED IN GROSS INCOME. (In accordance with Title 33,
YEAR
V.I.C. Chapter 13, Sections 250 (b) and (c)).
FORM 241VI
__________
ATTACH THIS FORM IN DUPLICATE TO YOUR INCOME TAX
RETURN.
Name and Address of Taxpayer:
Social Security Number
Date
Amount
___________________
$ ___________________
___________________
$ ___________________
Amounts Won in the Virgin Islands
___________________
$ ___________________
Lottery For Taxable Year
___________________
$ ___________________
TOTAL
$ ____________________
0.00
THE FOLLOWING INFORMATION MUST BE COMPLETED (In accordance with Section 934, Internal Revenue Code)
1. Were you a citizen of the United States during the entire tax year?
Yes _______
No ________
2. Were you a bona fide resident of the U.S Virgin Islands during the
entire tax year?
Yes _______
No ________
3. State the date on which you first became a bona fide resident of
U.S. Virgin Islands.
___________________________
4. (a) Did you maintain a place of abode for yourself or your family
during the tax year in the United States or elsewhere outside
the U.S. Virgin Islands?
Yes _______
No ________
(b) If answer is yes, state
(i) Location of place of abode ___________________________________________________________________
(ii) Purposes for which it was maintained - __________________________________________________________
_________________________________________________________________________________________
5. If you were absent from the U.S. Virgin Islands during the taxable year, state the beginning and the ending dates of
each absence:
Beginning Date
Ending Date
_______________________
_____________________
_______________________
_____________________
_______________________
_____________________
Under penalties of perjury, I declare that I have examined this claim, including accompanying schedules and statements, and to the
best of my knowledge and belief it is true, correct and, complete.
Dated _____________________, 20______
Signed :_______________________________________________________
_______________________________________________________