Form D-40b - Nonresident Request For Refund - 2015
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1Government of the
*150401110000*
D-40B Nonresident
2015
District of Columbia
Request for Refund
Important: Print in CAPITAL letters using black ink. Leave lines blank that do not apply.
Personal information
OFFICIAL USE ONLY
Vendor ID#0000
Your first name
Last name
M.I.
Your social security number
Your date of birth (MMDDYYYY)
Daytime phone number
Current mailing address (number, street and suite/apartment number if applicable)
City
State
Zip Code + 4
Country or U.S. commonwealth/U.S. territory
Review categories 1 - 2 below and attach your withholding statements.
1. Commuter/Domiciliary State Exemption: I declare that during the taxable year shown above I either commuted on a daily basis
from my place of residence to work in the District of Columbia (DC) or I was a domiciliary or legal resident of the state listed
and my only income from sources within DC was from wages and salaries, which are subject to taxation by (enter the 2 letter
state abbreviation for your domiciliary or legal state of residency) I did not maintain a place of abode in DC for a total of more
than 183 days. (see instructions). DC tax was erroneously withheld from salary and wages paid to me by my employer.
2. Military spouse exemption: If your non-resident military spouse was in the armed services during 2015, and you are not a DC
resident, enter the state of domicile declared on DD Form 2058.
3. List the type and location of any DC real property you own.
Type of property
Address (number, street and suite/apartment number if applicable)
Type of property
Address (number, street and suite/apartment number if applicable)
Refund request
Round cents to nearest dollar. If amount is zero, leave line blank.
$
.00
1
1.
DC income tax withheld
Attach copies of your withholding statements.
$
.00
2
2.
2015 DC estimated income tax payments
$
.00
3
3.
Refund request
Add Lines 1 and 2.
Will the refund go to an account outside the US?
Yes
No
See instructions.
Refund Options:
For information on the tax refund card and program limitations, see instructions or visit our website otr.dc.gov/refundprepaidcards.
Mark one refund choice:
Direct Deposit
Tax Refund Card
Paper Check
Direct Deposit
I
f you want your refund deposited in your bank account, fill in type of account
checking
savings and enter the routing number and account
number below.
Routing Number
Account Number
Signature
Under penalties of law, I declare that I have examined this request and any attached statements, and, to the best of my knowledge, they are correct.
Your signature
Date
Preparer’s signature
Preparer’s Tax Identification Number (PTIN)
Revised 09/2015
2015 D-40B P1 Nonresident Request for Refund
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