2019 VIRGINIA SCHEDULE OF INCOME

Form 760PY
Page 1
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Your Name Your SSN

PART 1
Income Distribution
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SECTION A You (Include Spouse if Filing Status 2)
SCHEDULE OF INCOME
Form 760PY, Column A Column A1 Column A2 Column A3
— All Filers Must Complete Section A —
Federal Return While VA Resident While NOT VA Resident

1. Wages, salaries, tips, etc. ..................................... 1 .00 .00 .00

2. Interest and dividends .......................................... 2 .00 .00 .00

3. Pension and other income .................................... 3 .00 .00 .00

4. Gross income (add Lines 1, 2 and 3) ................... 4 .00 .00 .00

5. Adjustments to income: moving expenses ........... 5 .00 .00 .00

6. Other income adjustments (enclose explanation) 6 .00 .00 .00

7. Federal adjusted gross income
7 .00 .00 .00
(Line 4 less Lines 5 and 6)* ..................................

8. 1HW¿[HGGDWHFRQIRUPLW\PRGL¿FDWLRQV ................ 8 .00 .00 .00

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Income (add Lines 7 and 8) .................................. 9 .00 .00 .00
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SECTION B Enter Spouse’s Income When Filing Status 4 Is Claimed

SCHEDULE OF INCOME
Form 760PY, Column B Column B1 Column B2 Column B3
— Spouse Must Complete Section B if claiming Filing Status 4 —
Federal Return While VA Resident While NOT VA Resident

1. Wages, salaries, tips, etc. ..................................... 1 .00 .00 .00

2. Interest and dividends .......................................... 2 .00 .00 .00

3. Pension and other income .................................... 3 .00 .00 .00

4. Gross income (add Lines 1, 2 and 3) ................... 4 .00 .00 .00

5. Adjustments to income: moving expenses ........... 5 .00 .00 .00

6. Other income adjustments (enclose explanation) 6 .00 .00 .00

7. Federal Adjusted gross income
7 .00 .00 .00
(Line 4 less Lines 5 and 6)**.................................

8. 1HW¿[HGGDWHFRQIRUPLW\PRGL¿FDWLRQV ................ 8 .00 .00 .00

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Income (add Lines 7 and 8) .................................. 9 .00 .00 .00
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2019 VIRGINIA SCHEDULE OF INCOME
Form 760PY
Page 2

Your Name Your SSN

PART 2
Prorated Exemptions Worksheet
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Prorated Virginia Personal Exemptions
Column B Column A
Spouse You
1. Your exemption ........................................ 1
2. Dependents ............................................ 2
3. Add Lines 1 and 2 .................................... 3
4. 0XOWLSO\/LQHE\ .............................. 4
5. 65 or over ............................................... 5
6. %OLQG ...................................................... 6
7. Add Lines 5 and 6 .................................... 7
8. 0XOWLSO\/LQHE\ .............................. 8
9. Add Lines 4 and 8 .................................... 9
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Exemption Ratio Schedule in the Form 
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result in the appropriate column on 11
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PART 3
Moving Information

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