763-S 2014
Va. Dept. of Taxation 763S F 2601046 Rev. 08/14
Include Copy of W-2 here
*VA763S114888*
Virginia Special Nonresident Claim
For Individual Income Tax Withheld
Date of Birth Your Birthday
(MM-DD-YYYY)
Primary Taxpayer Deceased (Include Federal Form 1310 if
applicable)
STEP I - Exemption Category
Review categories 1 - 4 below and enter the category number for which you are claiming an exemption
.
1 Commuter State Exemption: I declare that during the taxable year shown above I commuted on a
daily basis from my place of residence to work in Virginia. My only income from sources within Virginia
was from wages and salaries, which are subject to taxation by the state or district checked below. I
did not live in nor was I a domiciliary or legal resident of Virginia at any time.
Check One: District of Columbia Kentucky
2 Domiciliary State Exemption: I declare that during the taxable year shown above I was a domiciliary
or legal resident of the state checked below. My only income from sources within Virginia was from
wages and salaries, which are subject to taxation by the state checked below. I am not an actual
resident of Virginia and I did not maintain a place of abode in Virginia for a total of more than 183 days.
Check One: Maryland Pennsylvania West Virginia
3 Military Spouse Exemption: Complete the back of this form first. I declare that for the entire portion
of the year I lived in Virginia I was married to a service member on active military duty who was in
Virginia pursuant to military orders. I have not taken any action to abandon my domicile in another
state or to become a domiciliary or legal resident of Virginia. To be exempt, you and your spouse
must have the same domiciliary or legal state of residency. Enter the 2 letter state abbreviation for:
3(a) Your domiciliary or legal state of residency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3(b) Your spouse’s domiciliary or legal state of residency for military payroll purposes . . . . .
4 Tax Withheld in Error by Employer: I declare that during the taxable year shown above I was not
a domiciliary or legal resident of Virginia at any time. I did not perform any services in Virginia and
the Virginia tax was erroneously withheld from salary and wages paid to me by my employer.
Enter the 2 letter state abbreviation for your domiciliary or legal state of residency . . . . . . . . . . . .
STEP II - Enter amount of Virginia Tax withheld requested to be refunded:
If amended, enter the full refund amount as it should have been reported $
on the original return. You must provide copies of your withholding statements.
STEP III - Avoid delays: If you are a Resident of a State with an Individual Income Tax, attach a
complete copy of your State of Residence Income Tax Return and check this box.
If the Direct Deposit section below is not completed, your refund will be issued on a Debit Card.
Due by May 1, 2015. Mail to the Department of Taxation, P.O. Box 1498, Richmond, Virginia 23218-1498.
Each spouse must complete a separate Form 763-S when both filers have Virginia income tax withheld.
I, the undersigned, do declare under penalties provided by law that this is a true, correct and complete return.
Please
Sign Here
Your Signature
X
Date Your Phone
( )
Office Use
Preparers
Use Only
Preparer’s Name
X
Date Preparer’s Phone Number
Firm’s Name (or Yours if Self-employed) and Address Preparer’s FEIN/PTIN/SSN Code
- -
Your Bank Routing Transit Number
Account Number
Checking
Savings
DIRECT BANK DEPOSIT
Domestic Accounts Only
No International Deposits
First Name MI Last Name Suffix Your Social Security Number
Present Home Address (Number and Street, Including Apartment Number or Rural Route)
Spouse’s Social Security Number
City, Town or Post Office
State ZIP Code
I (we) authorize the Department of Taxation to discuss my (our) return with my (our) preparer.
Amended Claim
Military Spouse Qualification
Complete each question below and provide copies of the requested documentation before claiming Exemption Category 3
on the front of this form. Incomplete responses or missing documentation could cause your refund to be delayed. For information
regarding why the provisions of the Military Spouses Residency Relief Act apply only to spouses and not to dependents, see
Public Document 10-55 at www.tax.virginia.gov.
To qualify for the income tax exemption for military spouses you must have the same domicile as the military member and
meet all of the following qualifications:
I. Your spouse is a member of the armed forces present in Virginia in compliance with military orders.
1. Was your spouse in active military service for the taxable year in question? h Yes h No
a. If your spouse was discharged from full-time military service, what was
the date your spouse left the service? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
MM/DD/YYYY
b. If your spouse was in the military at any time for the taxable year in question, provide his or her duty station(s) for the taxable
year. Additional rows are provided in case your spouse had more than one duty station during the taxable year.
Location of Duty Station (include country if not USA) Date Assignment Started
MM/DD/YYYY
Date Assignment Ended
MM/DD/YYYY
2. Where and when were you and your spouse married? State
MM/DD/YYYY
3. Attach a copy of your military ID card. This would be a military identification card issued to spouses
of military personnel. If a military identification card has not been issued, check here.
4. What is your spouse’s state of domicile? (Enter here and on Line 3(b) on the front of this return)
Attach a copy of one or more of the following documents showing the military service member’s domicile or legal residence
(check the appropriate boxes to indicate which documents you are providing).
h Leave & Earning Statement (LES) for the year in question
h Current driver’s license from the military service member’s domicile state
h DD Form 2058 (State of Legal Residence Certificate)
h Other
II. You are present in Virginia solely to be with your spouse.
5. Do you own a business or any income producing property in Virginia? h Yes h No
a. If yes, please describe.
III. You maintain your domicile or legal residency in another state.
6. Do you claim the same state of domicile reported under question 4 above? h Yes h No
If you answered no, stop here. You do not qualify for tax relief. See Virginia Tax Bulletin 10-1 for details.
If you answered yes, please respond to the remaining questions.
a. Attach a copy of your state income tax return for the year in question. If your state of domicile
does not have an income tax, check here. h
b. When was the last period of time in which you and your service
member physically resided in that State? From
MM/DD/YYYY
To
MM/DD/YYYY
c. What was the last physical address in that state?
Street Address City State ZIP
d. Was your name different when you last physically resided in that state? h Yes h No
If Yes, what was your name?
First Name Middle Initial Last Name
7. Please attach a copy of one or more of the following documents showing your domicile or legal residence
(check the appropriate boxes to indicate which documents you are providing).
h Property tax bill from your domicile state
h Current driver’s license from your domicile state
h Other
Note: A copy of documents requested above will assist the Department in speeding up the issuance of the refund.