Virginia Resident Form 760 Web - Individual Income Tax Return

Virginia Resident Form 760 Web - Individual Income Tax Return - 2009 Page 3

Your Social Security Number

2009

*VA0ADJ109000*

Schedule ADJ

Virginia

(Form 760-ADJ)

Name(s) as shown on Virginia return

whole dollars only

Additions to Federal Adjusted Gross Income

Interest on obligations of other states, exempt from federal income tax but not from state tax ............ 1

Other additions to federal adjusted gross income

2a. FIxeD DAte conFormIty ADDItIon - See InStructIonS ............................................... 2a

2b - 2c Refer to the Form 760 instruction book for Other Addition

Enter Code

Enter Addition Amount

Codes

Total Additions. Add Lines 1 and 2a - 2c. Enter here and on Form 760, Line 2. ................................... 3

Subtractions from Federal Adjusted Gross Income

Income (interest, dividends or gains) from obligations or securities of the U.S. exempt

from state income tax, but not from federal tax .................................................................................... 4

Disability income reported as wages (or payments in lieu of wages) on your federal return

You ___________________________

Spouse __________________________Total

Other subtractions as provided in instructions

6a. FIxeD DAte conFormIty SubtrActIon - See InStructIonS ..................................... 6a

Enter Code

6b - 6d Refer to the Form 760 instruction book for Other Subtraction

Enter Subtraction Amount

Codes

Total subtractions. Add Lines 4, 5 and 6a - 6d. Enter here and on Form 760, Line 7. ......................... 7

Deductions from Virginia Adjusted Gross Income

Enter Code

Enter Deduction Amount

Refer to the Form 760 instruction book for Deduction Codes

loss

Total Deductions. Add Lines 8a - 8c. Enter here and on Form 760, Line 12. ........................................ 9

continue with Line 10 on Page 2

Avoid delays - If completed, attach Schedule ADJ to Form 760

Virginia Resident Form 760 Web - Individual Income Tax Return - 2009 Page 3