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763-S Virginia Special Nonresident Claim 2022 *VA763S122888*
For Individual Income Tax Withheld
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
Date of Birth Your Birthday - - Primary Taxpayer Deceased (Include Federal Form 1310 if
(MM-DD-YYYY) 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 to provide information
regarding your eligibility for this exemption. I declare that, for the entire portion of the taxable year I
lived in Virginia, I was present in the state solely to be with my servicemember spouse who was on
active military duty and in Virginia pursuant to military orders. To be exempt, either (1) you and your
servicemember spouse must have the same non-Virginia domiciliary or legal state of residency or
(2) you must elect to use the same residence for purposes of taxation as that of your servicemember
spouse. If you are claiming this exemption, enter the 2 letter state abbreviation for the domiciliary or
legal state of residency of your servicemember spouse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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.
DIRECT BANK DEPOSIT Your Bank Routing Transit Number Account Number Checking Savings
Domestic Accounts Only
No International Deposits
Due by May 1, 2023. 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.
I, the undersigned, do declare under penalties provided by law that this is a true, correct and complete return.
Please Your Signature Date Your Phone Office Use
Sign Here X
Preparer’s Preparer’s Name Date Preparer’s Phone Number
Use Only X
Firm’s Name (or Yours if Self-employed) and Address Preparer’s FEIN/PTIN/SSN Code
Va. Dept. of Taxation 763S F 2601046 Rev. 06/22
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