-15-
West Virginia
Special Nonresident Income Tax Return
2011
IT-140NRS
REV 08-11
*p40201111F*
Last Name Your Social Security Number
If you meet the described conditions, le
this return with the West Virginia State Tax
Department on or before April 17, 2012 for a
refund of West Virginia income taxes withheld
from wages and salaries.
First Name MI
Address
Amended
Return (check box)
City State Zip Code
NOTE: Use this form ONLY if you were a resident of Kentucky, Virginia, Pennsylvania, Maryland, or Ohio during the tax year of 2011, West Virginia
source income was from wages and salaries and West Virginia income tax was withheld from such wages and salaries by your employer(s). You must
complete IT-140W to verify West Virginia income tax withheld in order to receive credit. If you were a resident of a state other than Kentucky, Virginia,
Pennsylvania, Maryland, or Ohio, you must check the box Filing as a Nonresident/Part-Year Resident on Form IT-140 to report any income from West
Virginia sources.
If you were a domicilary resident of Pennsylvania or Virginia and spent more than 183 days within West Virginia during 2011, you are also considered a
resident of West Virginia for income tax purposes. Therefore, you are not eligible to le this return and must le Form IT-140 as a resident of West Virginia.
SPECIFIC INSTRUCTIONS ARE ON THE BACK AND PAGE 27
I declare that I was not a resident of West Virginia any time during 2011, I was a resident of the state shown, my only income from sources within West
Virginia was from wages and salaries, and such wages and salaries were subject to income taxation by my state of residence.
YOUR STATE OF RESIDENCE (Check one):
1.
Commonwealth of Kentucky
2.
State of Maryland
3.
State of Ohio
4.
Commonwealth of Virginia Number of days spent in West Virginia __________________
5.
Commonwealth of Pennsylvania Number of days spent in West Virginia __________________
1. Enter your total West Virginia income from wages and salaries.................................................................. 1 .00
2. Enter total amount of West Virginia Income Tax Withheld from your wages and salaries paid by your
employer in 2011 (Must complete Withholding tax schedule, page 7)........................................................ 2 .00
3. Overpayment previously refunded or credited (Amended Return Only)..................................................... 3 .00
4. West Virginia Children’s Trust Fund to help prevent child abuse and neglect
Enter the amount of your contribution
$5 $25 $100 Other $___________.......................... 4 .00
5. Refund Due You (subtract lines 3 and 4 from line 2)
Refund of $2 or less will be issued only if a written request is attached to this form.................................. 5 .00
Direct
Deposit
of Refund
CHECKING SAVINGS
ROUTING NUMBER ACCOUNT NUMBER
Under penalties of perjury, I declare that I have examined this return, accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. I authorize the State Tax Department to discuss my return with my preparer. YES NO
Your Signature Date Telephone Number
Signature of preparer other than above Date Address Daytime Phone Number
Preparer’s EIN
MAIL TO:
REFUND
WV State Tax Department
P.O. Box 1071
Charleston, WV 25324-1071
BALANCE DUE
WV State Tax Department
P.O. Box 3694
Charleston, WV 25336-3694
Preparer: Check here if
client is requesting that
form NOT be e-led.
F
Check your return for errors
* Indicates Required Field for Filing
Click Here for Specific Instructions for This Form
