Virginia Resident Form 760-Web - Individual Income Tax Return

Your SSN

Page 2

*VA0760203888*

Form 760-Web

2003

Year

15. Amount of Tax from Tax Table or Tax Rate Schedule (round to whole dollars) .............................. 15

16. Spouse Tax Adjustment. For Filing Status 2 only. Enter VAGI in whole dollars below. See instructions.

16a - Enter Your VAGI below

16b - Enter Spouse’s VAGI below

LOSS

.00

17. Net Amount of Tax - Subtract line 16 from line 15 ........................................................... 17

18. Virginia tax withheld for 2003.

18a. Your Virginia withholding ............................................................................................. 18a

18b. Spouse’s Virginia withholding (filing status 2 only) ......................................................... 18b

19. Estimated Tax Paid for tax year 2003 (from Form 760ES) ........................................................ 19

(include overpayment credited from tax year 2002)

20. Extension Payments (from Form 760E)................................................................................. 20

21. Tax Credit for Low Income Individuals from attached Schedule ADJ, line 12 .............................. 21

22. Credit for Tax Paid to Another State from attached Sch. ADJ, line 19 or Sch. OSC, line 41 .......... 22

(You must attach Sch. ADJ or Sch. OSC and a copy of all other state returns)

23. Other Credits from attached Schedule CR

...........................................................................

( If claiming Political Contribution Credit only - fill in oval - see instructions)

24. Add lines 18a, 18b and 19 through 23 ............................................................................... 24

If you are filing an Amended Return, stop here and GO TO line 27 of Schedule ADJ

25. If line 24 is less than line 17, subtract line 24 from line 17. This is the Tax You Owe .................... 25

Skip to line 28

26. If line 17 is less than line 24, subtract line 17 from line 24. This is Your Tax Overpayment ............ 26

27. Amount of overpayment you want credited to next year’s estimated tax ..................................... 27

28. Adjustments and Voluntary Contributions from attached Schedule ADJ, line 26 ........................... 28

(You must attach Schedule ADJ)

29. Add line 27 and line 28 ........................................................................................................ 29

30. If you owe tax on line 25, add lines 25 and 29. OR

If line 26 is less than line 29, subtract line 26 from line 29. AMOUNT YOU OWE .................... 30

CREDIT

ILL IN OVAL IF PAYING BY CREDIT CARD

SEE INSTRUCTIONS

CARD

31. If line 26 is greater than line 29, subtract line 29 from line 26. YOUR REFUND ............................ 31

Refund Only

Direct Deposit Information

Please indicate type of account

Checking

Savings

Your bank’s routing transit number

Your bank account number

I authorize the Dept. of Taxation to discuss my return with my preparer.

Fill in all ovals that apply:

Fill in oval if return was completed by a paid preparer

Qualifying farmer, fisherman or merchant seaman

Coalfield credit earned

Primary taxpayer deceased

Spouse deceased

Overseas on due date

I (We), the undersigned, declare under penalty of 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 Signature

Date

Spouse’s Signature

Date

Your business phone number

Home phone number

Spouse’s business phone number

Phone Number

Date

Preparer’s Name (please print)

SEE INSTRUCTIONS FOR ADDRESS TO MAIL YOUR RETURN

Virginia Resident Form 760-Web - Individual Income Tax Return - 2003 Page 2

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