Form D-40b - Nonresident Request For Refund - 2011 Page 2
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D-40B PAGE 2
Enter your last name.
Enter your social security number.
Other information
9
Place of birth, City
State
Date of birth (MM/DD/YY)
M M D D Y Y
10 State where you last voted
Date you voted
Yes
No
Are you registered to vote in DC?
11
Complete only if you were in military service during 2011.
State where enlisted
Enlistment date
State of domicile declared on DD Form 2058
Residence at time of enlistment
(MM/DD/YY)
State
or Country or U.S. commonwealth/U.S. territory
Employment history
12
Current employer
From (MM/DD/YY)
Current employer’s address (number and street)
City
State
Zip Code
Previous employer
From (MM/DD/YY)
To (MM/DD/YY)
Previous employer’s address (number and street)
City
State
Zip Code
Property information
13
List the type and location of any DC real property you own.
Type of property
Address (number, street and zip code)
Type of property
Address (number, street and zip code)
14
List amount of income tax and/or intangible personal property tax you paid in 2011 to the jurisdiction of your 2011 permanent residence listed on Line 7.
Amount
.00
$
Income tax
Fill in tax type:
.00
$
Intangible personal property tax
Signature
Under penalties of law, I declare that I have examined this request and any attached statements, and, to the best of my knowledge, it is correct.
Preparer’s signature
Your signature
Date
Send the completed D-40B to:
Office of Tax and Revenue, PO Box 209, Washington DC 20044-0209
Preparer’s PTIN
How will we respond to your request?
Who must file a Form D-40B?
• We will send you a refund for the amount you request if we determine you were not a resident
Any nonresident of DC claiming a refund of DC income tax
of DC during 2011; or
withheld or paid by estimated tax payments must file a
• Based on the information you provide, we may determine that you qualify as a DC resident. If so,
D-40B. A nonresident is anyone whose permanent home
we will send you a notice of your residency status and require that you file either a DC Form D-40
was outside DC during all of 2011 and who did not live in
DC for a total of 183 days or more during 2011. A joint
or DC Form D-40EZ tax return.
request for refund is not permitted. Attach all statements
Notice: In order to comply with new banking rules, we will not issue a refund to or
showing DC withholding to the front of page 1.
through a foreign financial institution. Instead, we will issue a paper check.
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2011 Form D-40B P2
Nonresident Request for Refund page 2
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