Fillable Form 763 - Virginia Nonresident Income Tax Return

*VA0763216888*

2016 FORM 763

Page 2

Your Name

Your SSN

20a

Your Virginia income tax withheld. Enclose Forms W-2, W-2G, 1099 and VK-1. ..............................................

20a

20b

Spouse's Virginia income tax withheld. Enclose Forms W-2, W-2G, 1099 and VK-1. .......................................

20b

2016 Estimated Tax Payments.. .........................................................................................................................

2015 overpayment credited to 2016 estimated tax.............................................................................................

Extension Payment - submitted using Form 760IP. ............................................................................................

Credit for Low-Income Individuals or Virginia Earned Income Credit from Schedule 763 ADJ, Line 17. ...........

Total credits from Schedule OSC. ......................................................................................................................

Credit for Political Contributions .........................................................................................................................

Credits from Schedule CR, Section 5, Line 1A...................................................................................................

Total payments and credits. Add Lines 20a through 27. .............................................................................

If Line 19 is larger than Line 28, enter the difference. This is the INCOME TAX YOU OWE. ............................

If Line 28 is larger than Line 19, enter the difference. This is the OVERPAYMENT AMOUNT. .........................

Amount of overpayment on Line 30 to be CREDITED TO 2017 ESTIMATED INCOME TAX. ..................................

Virginia College Savings Plan Contributions from Schedule VAC, Part I, Line 6 ...............................................

Other Voluntary Contributions from Schedule VAC, Section II, Line 14 .............................................................

Addition to Tax, Penalty and Interest from enclosed Schedule 763 ADJ, Line 21. ...........................................

Sales and Use Tax is due on Internet, mail order, and out-of-state purchases (Consumer’s Use Tax).

See instructions. Do not leave blank. If you owe no sales and use tax, enter 00. ...........................................

Add Lines 31 through 35. ...................................................................................................................................

If you owe tax on Line 29, add Lines 29 and 36 - OR - If you have an overpayment on Line 30 and Line 36

is larger than Line 30, enter the difference. AMOUNT YOU OWE. Enclose payment or pay at

virginia.gov. .........Check here if paying by credit or debit card - See instructions. ....................................

If Line 30 is larger than Line 36, subtract Line 36 from Line 30. This is the amount to be REFUNDED TO YOU.

If the Direct Deposit section below is not completed, your refund will be issued by check.

Checking

Savings

DIRECT BANK DEPOSIT

Your Bank Routing Transit Number

Your Bank Account Number

Domestic Accounts Only

No International Deposits

Nonresident Allocation Percentage

A - All Sources

B - Virginia Sources

1. Wages, salaries, tips, etc.. .................................................................................

2. Interest income. .................................................................................................

3. Dividends. ..........................................................................................................

4. Alimony received. ..............................................................................................

5. Business income or loss. ...................................................................................

6. Capital gain or loss/capital gain distributions.....................................................

7. Other gains or losses.........................................................................................

8. Taxable pensions, annuities and IRA distributions. ...........................................

9. Rents, royalties, partnerships, estates, trusts, S corporations, etc....................

10. Farm income or loss. .........................................................................................

11. Other income. ....................................................................................................

12. Interest on obligations of other states from Schedule 763 ADJ, Line 1. ............

13. Lump-sum and accumulation distributions included on Sch. 763 ADJ, Line 3. .

14. TOTAL - Add Lines 1 through 13 and enter each column total here ..................

15. Nonresident allocation percentage - Divide Line 14 B, by Line 14 A. Compute

percentage to one decimal place (e.g., 5.4%). Enter on Page 1, Line 17.. .......

I (We) authorize the Dept. of Taxation to discuss this return with my (our) preparer.

I agree to obtain my Form 1099-G at virginia.gov.

I (We), the undersigned, declare under penalty provided by law that I (we) have examined this return and to the best of my (our) knowledge, it is a true, correct and complete return.

Your Phone Number

Date

Your Signature

Spouse’s Signature (If a joint return, both must sign)

Spouse’s Phone Number

Preparer’s PTIN

Vendor Code

Preparer’s Name

Firm’s Name (or Yours if Self-Employed)

Preparer’s Phone Number

Filing Election Code

Office Use Only