-1-
IT-140NRS
REV. 7-14 F
West Virginia
Special Nonresident Income Tax Return 2014
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 15, 2015 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
ELIGIBILITY: Use this form ONLY if you were a resident of Kentucky, Maryland, Ohio, Pennsylvania or Virginia AND:
• West Virginia source income was from wages and salaries.
• West Virginia income tax was withheld from such wages and salaries by your employer(s).
• If you were a domiciliary resident of Pennsylvania or Virginia and spent more than 183 days in West Virginia, you are also considered a resident
of West Virginia and must le Form IT-140 as a resident of West Virginia.
• If you were a resident of a state other than Kentucky, Maryland, Ohio, Pennsylvania or Virginia, you must check the box Filing as a Nonresident/
Part Year Resident on Form IT-140 and complete Schedule A to report any income from West Virginia sources.
SPECIFIC INSTRUCTIONS ARE ON THE BACK.
I declare that I was not a resident of West Virginia at any time during 2014, 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 Pennsylvania Number of days spent in West Virginia __________________
5.
Commonwealth of Virginia 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 2014......................................................................................................................................... 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
PLEASE REVIEW YOUR ACCOUNT INFORMATION FOR ACCURACY. PROVIDING INCORRECT ACCOUNT INFORMATION MAY
RESULT IN A $15.00 RETURNED PAYMENT CHARGE.
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: Check here if
client is requesting that
form NOT be e-led
MAIL TO:
WV State Tax Department
P.O. Box 1071
Charleston, WV 25324-1071
Preparer’s EIN
*p40201411F*
Check your return for errors
* Indicates Required Field for Filing
Click Here for Specific Instructions for This Form
