Form It-140nrs - Special Nonresident Income Tax Return - 2015 - Draft
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4West Virginia
IT-140NRS
2015
Special Nonresident Income Tax Return
REV. 7-15
Last Name
Your Social Security Number
If you meet the described conditions, file
this return with the West Virginia State Tax
First Name
MI
Department on or before April 18, 2016 for a
refund of West Virginia income taxes withheld
from wages and salaries.
Address
Amended
Return (check box)
City
State
Zip Code
ELIGIBILITY: Use this form ONLY if you were a resident of Kentucky, Maryland, Ohio, Pennsylvania or Virginia AND:
•
West Virginia source income was from wages and salaries.
•
West Virginia income tax was withheld from such wages and salaries by your employer(s).
•
If you were a domiciliary resident of Pennsylvania or Virginia and spent more than 183 days in West Virginia, you are also considered a resident
of West Virginia and must file Form IT-140 as a resident of West Virginia.
•
If you were a resident of a state other than Kentucky, Maryland, Ohio, Pennsylvania or Virginia, you must check the box Filing as a Nonresident/
Part Year Resident on Form IT-140 and complete Schedule A to report any income from West Virginia sources.
SPECIFIC INSTRUCTIONS ARE ON THE BACK.
I declare that I was not a resident of West Virginia at any time during 2015, I was a resident of the state shown, my only income from sources within
West Virginia was from wages and salaries, and such wages and salaries were subject to income taxation by my state of residence.
YOUR STATE OF RESIDENCE (Check one):
1.
Commonwealth of Kentucky
2.
State of Maryland
3.
State of Ohio
4.
Commonwealth of Pennsylvania Number of days spent in West Virginia
__________________
5.
Commonwealth of Virginia
Number of days spent in West Virginia
__________________
.00
1. Enter your total West Virginia income from wages and salaries..................................................................
1
2. Enter total amount of West Virginia Income Tax Withheld from your wages and salaries paid by your
.00
employer in 2015.........................................................................................................................................
2
.00
3. Overpayment previously refunded or credited (Amended Return Only).....................................................
3
4. West Virginia Children’s Trust Fund to help prevent child abuse and neglect
.00
Enter the amount of your contribution
$5
$25
$100
Other $___________..........................
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5. Refund Due You (subtract lines 3 and 4 from line 2)
.00
Refund of $2 or less will be issued only if a written request is attached to this form..................................
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Direct
Deposit
CHECKING
SAVINGS
ROUTING NUMBER
ACCOUNT NUMBER
of Refund
PLEASE REVIEW YOUR ACCOUNT INFORMATION FOR ACCURACY. PROVIDING INCORRECT ACCOUNT INFORMATION MAY
RESULT IN A $15.00 RETURNED PAYMENT CHARGE.
Under penalties of perjury, I declare that I have examined this return, accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, correct and complete. I authorize the State Tax Department to discuss my return with my preparer.
YES
NO
Your Signature
Date
Telephone Number
Signature of preparer other than above
Date
Address
Daytime Phone Number
MAIL TO:
Preparer: Check here if
WV State Tax Department
client is requesting that
P.O. Box 1071
Preparer’s EIN
form NOT be e-filed
Charleston, WV 25324-1071
*p40201511F*
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