Form D-40b - Nonresident Request For Refund - 2011
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1
2l
2011
D-40B Nonresident
Government of the
District of Columbia
*110401110000*
Request for Refund
OFFICIAL USE ONLY
Important: Print in CAPITAL letters using black ink. Leave lines blank that do not apply.
Vendor ID#0000
Personal information
Your first name
Last name
M.I.
Your social security number
Daytime phone number
Current mailing address
City
State
Zip Code + 4
Country or U.S. commonwealth/U.S. territory
D-40
D-40EZ
D-40B
FILL IN if you filed one of these DC forms in the previous year:
If you did not file, give the reason.
Refund request
attach a signed copy of your state return(s)
Round cents to nearest dollar. If amount is zero, leave line blank.
$
.00
1
1
Total gross income
.00
$
2
2
DC gross income
.00
$
3
3
DC income tax withheld
Attach copies of your W-2s and any other forms that show DC withholding.
.00
$
4
4
2011 DC estimated income tax payments
.00
$
5
5
Refund request
Add Lines 3 and 4.
Will the refund go to an account outside the US?
Yes
No
See instructions on page 2.
Direct Deposit
I
f you want your refund deposited in your bank account, fill in type of account
checking
savings and enter the routing number and account
number below.
Routing Number
Account Number
Residence information
(MM/DD)
(MM/DD)
6
2011 DC residence
From
To
DC address (number, street and zip code)
Zip Code + 4
7
2011 permanent residence
State
or Country or U.S. commonwealth/U.S. territory
Zip Code + 4
Yes
No
Did you return or do you intend to return to this permanent residence?
If yes, enter date you returned or intend to return
(MM/DD/YY)
Reason you lived in DC during 2011
Reason you moved to or intend to move out of DC
8
List the states where you resided during the last 3 years, beginning with your present residence.
State
From (MM/YY)
To (MM/YY)
State
From (MM/YY)
To (MM/YY)
d
a
If jurisdiction is other
than a state, please list
e
b
it on an attachment.
f
c
l
l
2011 D-40B P1
Revised 08/2011
Nonresident Request for Refund page 1
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