2014
*VA3ADJ114888*
Virginia Schedule 763 ADJ
(Form 763 ADJ)
Page 1
Your Name
Your SSN
Additions to Adjusted Gross Income
00
1. Interest on obligations of other states, exempt from federal income tax, but not from state tax.
1
2. Other additions to adjusted gross income.
00
2a. Fixed Date Conformity addition - See instructions ...............................................................
2a
2b - 2c. Refer to the Form 763 instructions for Other Addition Codes.
00
2b
2b
00
2c
2c
00
3. Total Additions. Add Lines 1, 2a - 2c. Enter here and on Form 763, Line 2. ..............................
3
Subtractions from Adjusted Gross Income
4. Income (interest, dividends or gains) from obligations or securities of the U.S. exempt from
00
state income tax, but not from federal tax ..................................................................................
4
5. Disability income reported as wages (or payments in lieu of wages) on your federal return. If
claiming this subtraction you cannot also claim Age Deduction. Claim the one that benefits
you most.
00
5a. Enter YOUR disability subtraction on 5a. ............................................................................
5a
00
5b. Enter SPOUSE’s disability subtraction on 5b, if claiming Filing status 2 ............................
5b
6. Other Subtractions as provided in instructions
00
6a. Fixed Date Conformity subtraction. See instructions............................................................
6a
6b - 6d. Refer to the Form 763 instructions for Other Subtraction Codes.
00
6b.
6b
00
6c.
6c
00
6d.
6d
00
7. Total Subtractions. Add Lines 4, 5a, 5b, and 6a - 6d. Enter here and on Form 763, Line 7. ......
7
Deductions from Virginia Adjusted Gross Income
8.
Refer to the Form 763 instructions for Deduction Codes.
00
8a.
8a
00
8b.
8b
00
8c.
8c
00
9. Total Deductions. Add Lines 8a - 8c. Enter here and on Form 763, Line 14 ..............................
9
Avoid delays - If completed, submit Schedule 763 ADJ with Form 763
VA Dept. of Taxation
2601045 763ADJ
REV 08/14