Fillable Form 763 - Virginia Nonresident Income Tax Return

*VA0763212888*

FORM 763 (2012)

Page 2

Your Name

Your SSN

Virginia Taxable Income computed as a resident. Subtract Line 15 from Line 9. ..............................................

Percentage from Nonresident Allocation Section below (Enter to one decimal place only). .........................

Nonresident Taxable Income. (Multiply Line 16 by percentage on Line 17). .....................................................

Income Tax from Tax Table or Tax Rate Schedule. . ...........................................................................................

20a

Your Virginia income tax withheld, Attach Forms W-2, W-2G, 1099 and VK-1. .................................................

20a

20b

Spouse's Virginia income tax withheld, Attach Forms W-2, W-2G, 1099 and VK-1. ..........................................

20b

2012 Estimated Tax Payments (Include credit from 2011). ................................................................................

Extension Payment - submitted using Form 760IP. ...........................................................................................

Tax Credit for Low Income Individuals or Virginia Earned Income Credit from Schedule 763 ADJ, Line 17. ....

Total credits from Schedule OSC. .....................................................................................................................

Credits from Schedule CR, Section 5, Line 1A. If claiming Political Contribution Credit only, check box. .

Total payments and credits. Add Lines 20a, 20b, 21, 22, 23, 24 and 25. ....................................................

If Line 19 is larger than Line 26, enter the difference. This is the INCOME TAX YOU OWE. Skip to Line 30. ..

If Line 26 is larger than Line 19, enter the difference. This is the OVERPAYMENT AMOUNT. ........................

Amount of overpayment on Line 28 to be CREDITED TO 2013 ESTIMATED INCOME TAX. ................................

Adjustments and Voluntary Contributions from attached Schedule 763 ADJ, Line 24. ....................................

Add Lines 29 and 30. .........................................................................................................................................

If you owe tax on Line 27, add Lines 27 and 31 - OR - If you have an overpayment on Line 28 and Line 31 is

larger than Line 28, enter the difference. This is the AMOUNT YOU OWE. Attach payment.

Check here if credit card payment has been made. .............................................................................

If Line 28 is larger than Line 31, subtract Line 31 from Line 28. This is the amount to be REFUNDED TO YOU.

PAPER REFUND CHECKS WILL NOT BE ISSUED. Choose Debit Card or Direct Deposit below.

DEBIT CARD

OR DIRECT BANK DEPOSIT

Your bank routing transit number

Type:

Check this box to have your

Checking

refund issued on a prepaid

Account number

Savings

debit card.

NONRESIDENT ALLOCATION PERCENTAGE. Enter negative numbers in brackets.

A - All Sources

B - Virginia Sources

1 Wages, salaries, tips, etc.. .................................................................................

2 Interest income. .................................................................................................

3 Dividends. ..........................................................................................................

4 Alimony received. ..............................................................................................

5 Business income or loss. ...................................................................................

6 Capital gain or loss/capital gain distributions.....................................................

7 Other gains or losses.........................................................................................

8 Taxable pensions, annuities and IRA distributions. ...........................................

9 Rents, royalties, partnerships, estates, trusts, S corporations, etc....................

10 Farm income or loss. .........................................................................................

11 Other income. ....................................................................................................

12 Interest on obligations of other states from Schedule 763 ADJ, Line 1. ............

13 Lump-sum distributions/accumulation distributions included on Schedule 763

ADJ, Line 3. .......................................................................................................

14 TOTAL - Add Lines 1 through 13 and enter each column total here ..................

15 Nonresident allocation percentage - Divide Line 14 B, by Line 14 A. Compute

percentage to one decimal place, but not more than 100% (example 5.4%).

ENTER here and on Line 17 on Page 2.. ..........................................................

I (We), the undersigned, declare under penalty provided by law that I (we) have examined this return and to the best of my (our) knowledge, it is a true, correct and complete return.

Please Sign

Your Signature

Date

Spouse’s Signature (If a joint return, both must sign)

Date

Here

Preparer’s Name

Firm’s Name (or Yours if Self-Employed)

Preparer's Phone Number

Preparer’s

Use Only

Attach A Complete Copy Of Your Federal Tax Return And All Other Required Virginia Attachments