Instructions for Form 1040

Virginia Special Nonresident Claim for Individual Income Tax Withheld (Form 763-S, 2017)

First Name MI Last Name Suffix Your Social Security Number

Present Home Address

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

Date of Birth Your Birthday (MM-DD-YYYY) Primary Taxpayer Deceased (Include Federal Form 1310 if applicable)

STEP I - Select 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 second page 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, enclose 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 by check.

Due by May 1, 2018. Mail to the Department of Taxation, P.O. Box 1498, Richmond, Virginia 23218-1498.

Both spouses must complete a separate Form 763-S when both filers have Virginia income tax withheld.

Your Bank Routing Transit Number Account Number

DIRECT BANK DEPOSIT Checking Savings

Domestic Accounts Only. No International Deposits.

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.

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? Yes No

a. If your spouse was discharged from full-time military service, what was the date your spouse left the service?

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.

2. Where and when were you and your spouse married? State

3. Enclose a copy of your military ID card. If a military identification card has not been issued, check here.

4. What is your spouse’s state of domicile?

Enclose a copy of one or more of the following documents showing the military service member’s domicile or legal residence.

Leave & Earning Statement (LES) for the year in question

Current driver’s license from the military service member’s domicile state

DD Form 2058 (State of Legal Residence Certificate)

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? Yes 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? Yes No

If you answered no, stop here. You do not qualify for tax relief. If you answered yes, please respond to the remaining questions.

a. Enclose 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.

b. When was the last period of time in which you and your service member physically resided in that State? From To

c. What was the last physical address in that state?

Street Address

City State ZIP Code

d. Was your name different when you last physically resided in that state? Yes No

If Yes, what was your name?

7. Please enclose a copy of one or more of the following documents showing your domicile or legal residence.

Property tax bill from your domicile state

Current driver’s license from your domicile state

Other

Note: A copy of documents requested above will assist the Department in speeding up the issuance of the refund.