Form 763-S - Virginia Special Nonresident Claim For Individual Income Tax Withheld - 2012 Page 2
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2Military Spouse Qualification
Complete each question below and provide copies of the requested documentation, before claiming Exemption Category 3
on the front of this form. Incomplete responses or missing documentation could cause your refund to be delayed. For information
regarding why the provisions of the military spouse relief act apply only to spouses and not to dependents, see Public Document
10-55 at
To qualify for the income tax exemption for military spouses you must have the same domicile as the military member and
meet all of the following qualifications:
I. Your spouse is a member of the armed forces present in Virginia in compliance with military orders.
h
h
1. Was your spouse in active military service for the tax year in question?
Yes
No
a. If your spouse was discharged from full-time military service, what was
the date your spouse left the service? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
MM/DD/YYYY
b. If your spouse was in the military at any time for the tax year in question, provide his or her duty station(s) for the tax year.
Additional rows are provided in case your spouse had more than one duty station during the year.
Location of Duty Station (include country if not USA)
Date Assignment Started
Date Assignment Ended
MM/DD/YYYY
MM/DD/YYYY
2. Where and when were you and your spouse married? State
MM/DD/YYYY
3. Attach a copy of your military ID card. This would be a military identification card issued to spouses
h
of military personnel. If a military identification card has not been issued, check here.
4. What is your spouse’s state of domicile? (Enter here and on line 3(b) on the front of this return)
Attach a copy of one or more of the following documents showing the military service member’s domicile or legal residence
(check the appropriate boxes to indicate which documents you are providing).
h
Leave & Earning Statement (LES) for the year in question
h
Current driver’s license from the military service member’s domicile state
h
DD Form 2058 (State of Legal Residence Certificate)
h
Other
II. You are present in Virginia solely to be with your spouse.
h
h
5. Do you own a business or any income producing property in Virginia?
Yes
No
a. If yes, please describe.
III. You maintain your domicile or legal residency in another state.
h
h
6. Do you claim the same state of domicile reported under question 4 above?
Yes
No
If you answered no, stop here. You do not qualify for tax relief. See Virginia Tax Bulletin 10-1 for details.
If you answered yes, please respond to the remaining questions.
a. Attach a copy of your state income tax return for the year in question. If your state of domicile
h
does not have an income tax, check here.
b. When was the last period of time in which you and your service
member physically resided in that State? From
To
MM/DD/YYYY
MM/DD/YYYY
c. What was the last physical address in that state?
Street Address
City
State
ZIP
h
h
d. Was your name different when you last physically resided in that state?
Yes
No
If Yes, what was your name?
First Name
Middle Initial
Last Name
7. Please attach a copy of one or more of the following documents showing your domicile or legal residence
(check the appropriate boxes to indicate which documents you are providing).
h
Property tax bill from your domicile state
h
Current driver’s license from your domicile state
h
Other
Note: A copy of documents requested above will assist us in speeding up the issuance of the refund.
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