*VA0763221888*
2021 FORM 763 Page 2
I (We), the undersigned, declare under penalty provided by law that I (we) have examined this return and to the best of my (our) knowledge, it is a true, correct, and complete return.
19a Your Virginia income tax withheld. Enclose Forms W-2, W-2G, 1099, and VK-1. ............................................. 19a 00
19b Spouse's Virginia income tax withheld. Enclose Forms W-2, W-2G, 1099, and VK-1. ...................................... 19b 00
20 2021 Estimated Tax Payments.. ......................................................................................................................... 20 00
21 2020 overpayment credited to 2021 estimated tax............................................................................................. 21 00
22 Extension Payment - submitted using Form 760IP. ............................................................................................ 22 00
23 Credit for Low-Income Individuals or Virginia Earned Income Credit from Schedule 763 ADJ, Line 17. ........... 23 00
24 Total credits from Schedule OSC. ...................................................................................................................... 24 00
25
Credits from Schedule CR, Section 5, Line 1A................................................................................................... 25 00
26 Total payments and credits. Add Lines 19a through 25. ............................................................................. 26 00
27 If Line 18 is larger than Line 26, enter the dierence. This is the INCOME TAX YOU OWE. ............................ 27 00
28 If Line 26 is larger than Line 18, enter the dierence. This is the OVERPAYMENT AMOUNT. ......................... 28 00
29 Amount of overpayment on Line 28 to be CREDITED TO 2022 ESTIMATED INCOME TAX. .............................. 29 00
30 Virginia529 and ABLE Contributions from Schedule VAC, Part I, Line 6 ............................................................ 30 00
31 Other Voluntary Contributions from Schedule VAC, Section II, Line 14 ............................................................. 31 00
32 Addition to Tax, Penalty, and Interest from enclosed Schedule 763 ADJ, Line 21. .......................................... 32 00
33
Sales and Use Tax is due on Internet, mail order, and out-of-state purchases (Consumer’s Use Tax).
See instructions. .................................... Check here if no sales and use tax is due. ...................................
33 00
34 Add Lines 29 through 33. ................................................................................................................................. 34 00
35 If you owe tax on Line 27, add Lines 27 and 34 - OR - If you have an overpayment on Line 28 and
Line 34 is larger than Line 28, enter the dierence. AMOUNT YOU OWE. Enclose payment or pay at
www.tax.virginia.gov. ........Check here if paying by credit or debit card - See instructions. ......................
35 00
36 If Line 28 is larger than Line 34, subtract Line 34 from Line 28. This is the amount to be REFUNDED TO YOU. 36 00
I (We) authorize the Dept. of Taxation to discuss this return with my (our) preparer. I agree to obtain my Form 1099-G at www.tax.virginia.gov.
Your Bank Routing Transit Number
Your Bank Account Number
Checking
Savings
If the Direct Deposit section below is not completed, your refund will be issued by check.
DIRECT BANK DEPOSIT
Domestic Accounts Only
No International Deposits
Your Name Your SSN
Nonresident Allocation Percentage
A - All Sources B - Virginia Sources
1. Wages, salaries, tips, etc.. ................................................................................. 1 00 00
2. Interest income. ................................................................................................. 2 00 00
3. Dividends. .......................................................................................................... 3 00 00
4. Alimony received. .............................................................................................. 4 00 00
5. Business income or loss. ................................................................................... 5 00 00
6. Capital gain or loss/capital gain distributions..................................................... 6 00 00
7. Other gains or losses......................................................................................... 7 00 00
8. Taxable pensions, annuities and IRA distributions. ........................................... 8 00
9. Rents, royalties, partnerships, estates, trusts, S corporations, etc.................... 9 00 00
10. Farm income or loss. ......................................................................................... 10 00 00
11. Other income. .................................................................................................... 11 00 00
12. Interest on obligations of other states from Schedule 763 ADJ, Line 1. ............ 12 00
13. Lump-sum and accumulation distributions included on Sch. 763 ADJ, Line 3. . 13 00 00
14. TOTAL - Add Lines 1 through 13 and enter each column total here .................. 14 00 00
15. Nonresident allocation percentage - Divide Line 14 B, by Line 14 A. Compute
percentage to one decimal place (e.g., 5.4%). Enter on Page 1, Line 16. ........ 15
%
Your Signature
Your Phone Number Date
Spouse’s Signature (If a joint return, both must sign) Spouse’s Phone Number Preparer’s PTIN Vendor Code
Preparer’s Name Firm’s Name (or Yours if Self-Employed) Preparer’s Phone Number Filing Election Code ID Theft PIN
