2022 Virginia Unified Nonresident 

Schedule L Individual Income Tax Return *VA765L122888*
(Form 765) List of Participants

Name of Pass-Through Entity FEIN

Identify the Participants

Guaranteed 
SSN Name/Address Allocation %
Payment Amount

1. .

2. .

3. .

4. .

5. .

6. .

7. .

8. .

9. .
Rev. 07/22

6201039-W 10. .

Substitute versions of this form that are produced using computer software must provide the same information in the same 
Va. Dept. of Taxation 4-column format as shown on the official version of this form. Minimum font size is 10 point.