Form D-40B Fillable 2015 Nonresident Request for Refund
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

Address (number street and suite/apartment number if applicable) Based on the information you provide we may determine that you determine you were not a resident of DC during 2015; or Mark one refund choice: Direct Deposit Tax Refund Card Paper Check Personal information Refund Options: For information on the tax refund card and program limitations see instructions or visit our website otr dc gov/refundprepaidcards We will send you a refund for the amount you request if we Your signature Date Preparer s signature *150401110002* 1 $ 00 1 Commuter/Domiciliary State Exemption: I declare that during the taxable year shown above I either commuted on a daily basis 1 DC income tax withheld Attach copies of your withholding statements 183 days or more during 2015 A joint request for refund is not 2 $ 00 2 2015 DC estimated income tax payments 2 Military spouse exemption: If your non resident military spouse was in the armed services during 2015 and you are not a DC 2015 D 40B P1 Nonresident Request for Refund 2015 Form D 40B P2 Nonresident Request for Refund 3 $ 00 3 List the type and location of any DC real property you own 3 Refund request Add Lines 1 and 2 A nonresident is anyone whose permanent home was outside a paper check a paper check will be issued Address (number street and suite/apartment number if applicable) and my only income from sources within DC was from wages and salaries which are subject to taxation by (enter the 2 letter Any nonresident of DC claiming a refund of DC income tax BEHIND but less than or equal to $4 000 If the refund is outside the threshold City State Zip Code + 4 considered a DC resident and the 183 days does not apply Country or U S commonwealth/U S territory Current mailing address (number street and suite/apartment number if applicable) D 40B NonresidentRequest for Refund DC during all of 2015 and who did not live in DC for a total of DC Form D 40 or DC Form D 40EZ tax return Direct Deposit If you want your refund deposited in your bank account fill in type of account checking savings and enter the routing number and account number below District of Columbia from my place of residence to work in the District of Columbia (DC) or I was a domiciliary or legal resident of the state listed front of page 1 Be sure to include your date of birth on page 1 Government of the How will we respond to your request? In the event of a rejection of direct deposit refunds will be re issued on issue a tax refund card if the refund is greater than or equal to $2 00 NOTE: If you moved into DC with the intent of residing you are Notice: In order to comply with banking rules we will not issue a OFFICIAL USE ONLY permitted Attach all statements showing DC withholding to the Preparer s Tax Identification Number (PTIN) qualify as a DC resident If so we will require that you file either a Refund request refund to or through a foreign financial institution Instead we will resident enter the state of domicile declared on DD Form 2058 Review categories 1 2 below and attach your withholding statements Revised 09/2015 Round cents to nearest dollar If amount is zero leave line blank Routing Number Account Number Signature Under penalties of law I declare that I have examined this request and any attached statements and to the best of my knowledge they are correct STAPLE OTHER REQUESTED DOCUMENTS IN UPPER LEFT STAPLE W 2s AND OTHER WITHHOLDING STATEMENTS HERE state abbreviation for your domiciliary or legal state of residency) I did not maintain a place of abode in DC for a total of more than 183 days (see instructions) DC tax was erroneously withheld from salary and wages paid to me by my employer THIS FORM Type of property Vendor ID#0002 Who must file a Form D 40B? Will the refund go to an account outside the US? YesNo See instructions withheld or paid by estimated tax payments must file a D 40B Your first name M I Last name Your social security number Your date of birth (MMDDYYYY) Daytime phone number