Virginia Schedule 763 Adj (Form 763 Adj) - 2012 Page 2
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2*VA3ADJ212888*
2012 Virginia Schedule 763 ADJ
Page 2
Your Name
Your SSN
Tax Credit For Low Income Individuals or Virginia Earned Income Credit - SEE INSTRUCTIONS
Family VAGI
Name
Social Security Number (SSN)
Guideline Income
Yourself
-
-
00
Spouse
-
-
00
a. Dependent
-
-
00
b. Dependent
-
-
00
10. If more than 4 exemptions, attach schedule listing the name, SSN & VAGI.
10
00
Enter total Family Guideline Income here.
11.
Enter the total number of exemptions reported in the table above. Next, go to the Poverty
Guidelines Table shown in the Form 763 instruction book for this Line to see if you qualify for this
credit ....................................................................................................................................
11
12.
If you qualify, enter the number of personal exemptions reported on your Form 763...........
12
13.
Multiply Line 12 by $300. Enter the result on Line 13 and proceed to Line 14. If you do not qualify
for the Tax Credit for Low Income Individuals, but claimed an Earned Income Credit on your
00
federal return, enter $0 and proceed to Line 14.........................................................................
13
14.
Enter the amount of Earned Income Credit claimed on your federal return. If you did not claim an
00
Earned Income Credit on your federal return, enter $0........................................................
14
15.
Multiply Line 14 by 20% (.20)................................................................................................
00
15
16.
Enter the greater of Line 13 or Line 15.................................................................................
00
16
17.
Compare the amount on Line 16 above to the amount of tax on Form 763, Line 19. Enter the
00
lesser of the two amounts here and on Form 763, Line 23. This is your credit amount......
17
Adjustments and Voluntary Contributions
18. Addition to tax. Check if addition came
from:
.......
Form 760C
Form 760F.........
00
18
19. Penalty..................................................................
Late Filing Penalty
Extension Penalty
00
19
20. Interest (interest accrued on the tax you owe)....................................................................
00
20
21. Consumer’s Use Tax............................................................................................................
00
21
22. Voluntary Contributions. Enter the code for the
00
contribution(s) and the contribution amount(s) in boxes
22a
22a
22a - 22c. If contributing to more than 3 Voluntary
Contributions, see Form 763 instructions.
00
22b
22b
00
22c
22c
23.
If contributing to a School Foundation or a Library
00
Foundation, enter the code for the foundation(s) and the
23a
23a
contribution amount(s) in boxes 23a - 23c. If contributing
to more than 3 school or library foundations, see Form
00
763 instructions.
23b
23b
00
23c
23c
00
24.
Total Adjustments (add Lines 18 - 23c). Enter here and on Form 763, Line 30...................
24
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