Address Starts here - Virginia Tax



REQUEST FOR DOMICILE QUESTIONNAIRE

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CCRETAXPAYERNAME

Virginia Tax Account Number TAXACCTNUM

Tax Type: Individual Income CASEIDAUDIT_TEXT

Dear Customer:

Thank you for your recent letter concerning your UTAXPERIOD Virginia individual income tax liability.

To assist us in making a proper determination of your residency status, please complete and sign the General Domicile Questionnaire beginning on the back of this letter. SELECTIONVARNREQ

Please return your completed General Domicile Questionnaire to the address shown below by RESPONSEDATE30. You may wish to keep a copy of this letter for your records.

If you have any questions or need assistance, please call us at USERPHONE, or write to USERDISPLAYNAME, USERTITLE, USEROFFICE, USERSECTION, USERUNIT, USERADDRLINE1, USERADDRLINE2.

Enclosed: General Domicile Questionnaire

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|CCNAME CCADDRESSLINE1 CCADDRESSLINE2 CCADDRESSLINE3 |

GENERAL DOMICILE QUESTIONNAIRE

You are requested to answer the following questions completely and accurately so that the Virginia Department of Taxation may have sufficient facts in making a proper determination of your Virginia state income tax liability.

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|YOUR FULL NAME | |YOUR SOCIAL SECURITY NUMBER |

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|SPOUSE’S FULL NAME | |SPOUSE’S SOCIAL SECURITY NUMBER |

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YOUR PRESENT ADDRESS

1. Date and place of birth: ________________________________________________.

2. Present address of your parents: ________________________________________.

3. If you are married: (a) When and where were you married? ____________________. (b) Of what state were you a resident on date of marriage? ____________________. (c) Of what state was your spouse a resident on date of marriage?_______________.

4. Give periods during which you have lived in Virginia and the address at which you lived for each period.

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|Month: |Year: |Month: |Year: | |

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5. Give periods during which you have lived outside of Virginia and the address at which you lived for each period.

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|Month: |Year: |Month: |Year: | |

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6. If you are married, did your spouse and children reside with you during the periods covered by Item 5? __________. If not, give the state or states in which they resided and the periods:

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7. Have you ever purchased a home in Virginia? __________. When? ____________. Where? ____________. Do you currently own this home? __________? If not, when did you dispose of the home? ____________.

8. Have you ever purchased a home outside of Virginia? __________. When? _________. Where? ____________. Do you currently own this home? __________. If not, when did you dispose of the home? ____________.

9. Have you any children attending the public free schools in Virginia? __________.

10. Do you maintain accounts (such as banking, savings, credit, charge, etc.) within Virginia? __________.

11. Are you registered to vote in Virginia? __________. If YES, when did you register to vote in Virginia? __________. When did you last vote in Virginia? __________. If not in Virginia, in what state did you last vote? __________. When? __________.

12. Have you paid a state income tax to any state during one or more of the last six years? __________. If YES, to what state and for what year(s)? _______________________.

13. Have you paid any state or local property taxes anywhere during the last six years? __________. If YES, in what state and locality were they paid and for what years? _______________________.

14. Does your automobile bear Virginia license plates for the current year? __________. If YES, what years has this car (and its predecessors) born Virginia license plates? ____________________. If your automobile does not bear Virginia license plates, what state’s license plates does it bear? ____________________.

15. Do you hold a Virginia motor vehicle operator’s license? __________. If YES, when were you first licensed in Virginia? __________. If this license was not renewed, give reason(s). _________________________. If you do not now hold a Virginia operator’s license, what state’s operator’s license do you hold? ____________________.

16. Have you ever received or earned any income from property located, business done, or services performed in Virginia? __________. If YES, during what years? _________________________.

17. Who currently employes you? _________________________. Who employed you during each of the last three years? _________________________________________________________.

18. If you were married during each of the last three years, did your spouse receive any gross income? __________. If YES, what type of income was received?__________________ ____________________. Where was the income earned? ________________________.

19. If you are residing in Virginia, do you intend to stay indefinitely? __________. If not, when do you intend to leave Virginia? __________. Why? _______________________________________________________________.

20. Name of state of your claimed legal residence: _________________________. Explain briefly here, or on a separate sheet, any ties, connections, or interests of a business or personal nature you may still have in that state.

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21. If you are not living in Virginia now but formerly lived in Virginia and claim to be a legal resident of another state, explain briefly here, or on a separate sheet, any ties, connections or interest of a business or personal nature you may still have in Virginia.

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22. Are you a U.S. citizen? ______. Were you living outside of the United States? ______. Did you qualify for the foreign income exclusion on your federal return? ______. Do/Did you have a resident visa? ______. Do/Did you have a work visa/permit? ______. How long have you lived outside the U.S.? __________. Which state was your state of legal domicile before leaving the U.S.? __________________________. If you have moved back to the U.S., when, and what is your current state residence? ________________________.

23. If you are not a U.S. citizen, what is your country of citizenship? _____________________. Are you here as a college student? ______. Are you here as an employee of a U.S. company? ______. Are you living in Virginia, but employed by a foreign government? ______. Are there any tax treaties between your country and the Unites States that govern the taxability of your income? ______. If yes, please explain the nature of the treaty.

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24. If there is any other information you consider pertinent, please state the information below:

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I declare under penalties provided by law that, to the best of my knowledge and belief, the foregoing answers and statements are true and complete.

____________________________________ ____________________

SIGNATURE DATE

____________________________________ ____________________

SIGNATURE OF SPOUSE DATE

( NOTE: UNITED STATES MILITARY PERSONNEL MUST ALSO COMPLETE PAGE 4 )

DOMICILE INFORMATION FOR UNITED STATES MILITARY PERSONNEL

United States Military personnel must complete this page in addition to pages 1-4 of the General Domicile Questionnaire.

1. On what date, and with what branch, did you enter into active duty with the Armed Forces?

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2. In what state and at what address were you actually living at the time you were ordered to report for active duty with the Armed Forces?

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How long had you been actually living in such state? _____________________.

3. If you are currently not on active duty, on what date were you discharged from the Armed Forces? ____________________. Where did you live immediately after your discharge?

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4. If you are currently on active duty, where do you intend to live after your discharge from the Armed Forces?

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5. If you are married, where did your spouse and children live while you were in Virginia on active duty with the Armed Forces?

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6. If you were married during each of the last three years, did your spouse receive any gross income? __________. If yes, what type of income was received?

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7. Name the state of your claimed residence. ____________________________________. Explain briefly here, or on a separate sheet, any ties, connections, or interests of a business or personal nature you may have in that state.

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