Virginia Resident Form 760 - Individual Income Tax Return - 2012 Page 2

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Page 2



Your SSN

Form 760

2012

Year

15. Amount of Tax from Tax Table or Tax Rate Schedule (round to whole dollars) ...........................15

16. Spouse Tax Adjustment. For Filing Status 2 only. Enter VAGI in whole dollars below. See instructions.

16a - Enter Your VAGI below

16b - Enter Spouse’s VAGI below

LOSS

.00

17. Net Amount of Tax - Subtract Line 16 from Line 15 ...............................................................17

18. Virginia tax withheld for 2012.

18a. Your Virginia withholding ...................................................................................................18a

18b. Spouse’s Virginia withholding (ﬁ ling status 2 only) ...........................................................18b

19. Estimated Tax Paid for tax year 2012 (from Form 760ES) ...........................................................19

(include overpayment credited from tax year 2011)

20. Extension Payments (from Form 760IP) ......................................................................................20

21. Tax Credit for Low Income Individuals or Earned Income Credit from attached Sch. ADJ, Line 17 .....21

22. Credit for Tax Paid to Another State from attached Sch. OSC, Line 21 ......................................22

(You must attach Sch. OSC and a copy of all other state returns)

23. Other Credits from attached Schedule CR ................................................................................23

(If claiming Political Contribution Credit only - ﬁ ll in oval - see instructions)

24. Add Lines 18a, 18b and 19 through 23 ....................................................................................24

25. If Line 24 is less than Line 17, subtract Line 24 from Line 17. This is the Tax You Owe ............25

Skip to Line 28

26. If Line 17 is less than Line 24, subtract Line 17 from Line 24. This is Your Tax Overpayment ...26

27. Amount of overpayment you want credited to next year’s estimated tax ....................................27

28. Adjustments and Voluntary Contributions from attached Schedule ADJ, Line 24 .......................28

(You must attach Schedule ADJ)

29. Add Lines 27 and 28.....................................................................................................................29

30. If you owe tax on Line 25, add Lines 25 and 29. OR

If Line 26 is less than Line 29, subtract Line 26 from Line 29. AMOUNT YOU OWE ................30

FILL IN OVAL IF PAYING BY CREDIT OR DEBIT CARD

SEE INSTRUCTIONS

31. If Line 26 is greater than Line 29, subtract Line 29 from Line 26. YOUR REFUND ....................31

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

DEBIT CARD

DIRECT BANK DEPOSIT

Your bank routing transit number

Type:

Fill in this oval if you want

Checking

to have your refund issued

Account number

Savings

on a prepaid debit card.

Qualifying farmer, ﬁ sherman or merchant seaman

Federal Schedule C ﬁ led with federal return

Fill in all

ovals that

Earned Income Credit from federal return. Amount claimed:

Overseas on due date

apply:

Primary Taxpayer Deceased

Spouse Deceased

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

Your Signature

Date

Spouse’s Signature

Date

Your business phone number

Home phone number

Spouse’s business phone number

Filing

Preparer’s PTIN

Preparer’s Name

Firm Name

Phone Number