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2022 Virginia Schedule 763 ADJ
Page 1
Your Name Your SSN *VA3ADJ122888*

Additions to Adjusted Gross Income
1. Interest on obligations of other states, exempt from federal income tax, but not from state tax. 1 00

2. Other additions to adjusted gross income.
2a. Fixed Date Conformity addition - See instructions ............................................................... 2a 00
Code
2b - 2c. Refer to the Form 763 instructions for Other Addition Codes.
00
2b 2b
2c 2c 00

3. Total Additions. Add Lines 1, 2a - 2c. Enter here and on Form 763, Line 2. ............................. 3 00

Subtractions from Adjusted Gross Income
4. Income (interest, dividends or gains) from obligations or securities of the U.S. exempt from
state income tax, but not from federal tax .................................................................................. 4 00
5. Disability income reported as wages (or payments in lieu of wages) on your federal return. If
claiming this subtraction you cannot also claim Age Deduction. Claim the one that benefits
you most.
5a. Enter YOUR disability subtraction on 5a. ............................................................................ 5a 00

5b. Enter SPOUSE’s disability subtraction on 5b, if claiming Filing status 2 ............................ 5b 00

6. Other Subtractions as provided in instructions
6a. Fixed Date Conformity subtraction. See instructions............................................................ 6a 00
6b - 6d.Refer to the Form 763 instructions for Other Subtraction Codes.
Certification Number Code

6b 6b 00

6c. 6c 00

6d. 6d 00

7. Total Subtractions. Add Lines 4, 5a, 5b, and 6a - 6d. Enter here and on Form 763, Line 7. .... 7 00

Deductions from Virginia Adjusted Gross Income
Code
8. Refer to the Form 763 instructions for Deduction Codes.
00
8a. 8a
8b. 8b 00

8c. 8c 00

9. Total Deductions. Add Lines 8a - 8c. Enter here and on Form 763, Line 13 ............................. 9 00
Use Schedule ADJS if you are claiming more additions, subtractions or deductions than the Schedule
763 ADJ allows. Refer to the instructions for Other Codes.
Check this box. ...........................................................................................................................

VA Dept. of Taxation 2601045 763ADJ Rev. 07/22

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2022 Virginia Schedule 763 ADJPage 2
Your Name Your SSN *VA3ADJ222888*

Tax Credit for Low-Income Individuals or Virginia Earned Income Credit - SEE INSTRUCTIONS

Family VAGI Name Social Security Number (SSN) Guideline Income
Yourself - - 00
Spouse - - 00
Dependent - - 00
Dependent - - 00
10. If more than 4 exemptions, enclose schedule listing the name, SSN & VAGI.
10
Enter total Family Guideline Income here. 00
11. Enter the total number of exemptions reported in the table above. Next, go to the Poverty Guidelines
Table shown in the Form 763 instruction book for this Line to see if you qualify for this credit ........ 11
12. If you qualify, enter the number of personal and dependent exemptions reported on your Form
763 (see instructions). ....................................................................................................................... 12
13. Multiply Line 12 by $300. Enter the result on Line 13 and proceed to Line 14. If you do not qualify
for the Tax Credit for Low-Income Individuals, but claimed an Earned Income Credit on your federal 00
return, enter $0 and proceed to Line 14 ............................................................................................ ........................................................... 13
14. Enter the amount of Earned Income Credit claimed on your federal return. If you did not claim an
Earned Income Credit on your federal return, enter $0 ..................................................................... 14 00
15. Multiply Line 14 by 20% (.20) ............................................................................................................ 15 00
16. Enter the greater of Line 13 or Line 15 .............................................................................................. 16 00
17. Compare the amount on Line 16 above to the amount of tax on Form 763, Line 18. Enter the lesser
of the two amounts here and on Form 763, Line 23. This is your credit amount. .............................. 17 00

Addition to Tax, Penalty and Interest
18. Addition to tax ............................................................................................................................ ........ 18 00
19. Penalty.................................................................. Late Filing Penalty Extension Penalty 19 00
20. Interest (accrued on the tax you owe) ................................................................................................ 20 00
21. Total Addition to Tax, Penalty and Interest (add Lines 18 - 20). Enter here and on Form 763,
Line 32 ................................................................................................................................................ 21 00

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