2021 Virginia Schedule ADJ (Form 760-ADJ) *VA0ADJ121888* Name(s) as shown on Virginia return Dollar Amount Additions to Federal Adjusted Gross Income 1. Interest on obligations of other states, exempt from federal income tax but not from state tax.............. 1 2. Other additions to federal adjusted gross income.

2a. FIXED DATE CONFORMITY ADDITION - SEE INSTRUCTIONS................................................. 2a 2b - 2c. Refer to the Form 760 instructions for Other Addition Codes. 2b 2c 3. Total Additions. Add Lines 1 and 2a - 2c. Enter here and on Form 760, Line 2...................................... 3 Subtractions from Federal 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 5. Disability income reported as wages (or payments in lieu of wages) on your federal return.

5a. Enter YOUR disability subtraction................................................................................................... 5a

5b. Enter SPOUSE’s disability subtraction........................................................................................... 5b 6. Other subtractions as provided in instructions.

6a. FIXED DATE CONFORMITY SUBTRACTION - SEE INSTRUCTIONS......................................... 6a

6b - 6d. Refer to the Form 760 instructions for Other Subtraction Codes. 6b 6c 6d 7. Total Subtractions. Add Lines 4, 5a, 5b, and 6a - 6d. Enter here and on Form 760, Line 7.................... 7 . 00 , , . 00 , , . 00 , , . 00 , , . 00 , , . 00 , , . 00 , , . 00 , , . 00 , , . 00 , , . 00 , , . 00 , , . 00 , , Deductions from Virginia Adjusted Gross Income 8. Refer to the Form 760 instructions for Deduction Codes. 8a 8b 8c 9. Total Deductions. Add Lines 8a - 8c. Enter here and on Form 760, Line 13........................................... 9 Use Schedule ADJS if you are claiming more additions, subtractions or deductions than the Schedule ADJ allows. Refer to the Form 760 Instructions for Other Codes. Fill in this oval.....................................................

Continue with Line 10 on Page 2. loss . 00 , , loss . 00 , , loss . 00 , , loss . 00 , , Your Social Security Number - - Code Certification Number Code Code WEB

*VA0ADJ221888* 2021 Virginia Schedule ADJ Page 2 2601050 Rev. 06/21 18. Addition to tax. Fill in oval if addition came from: Form 760C Form 760F.... 18 19. Penalty Late Filing Penalty Extension Penalty .......................... 19 20. Interest (accrued on the tax you owe)........................................................................................ 20 21. Total Addition to Tax, Penalty, and Interest (add Lines 18 through 20). Enter here and on Line 32 of Form 760...................................................................................... 21 . 00 , , . 00 , , . 00 , , . 00 , , Addition to Tax, Penalty, and Interest 11. Enter the total number of exemptions reported in the table above. Next, refer to the Poverty Guidelines Table in the Form 760 instructions to see if you qualify for this credit.......................................................... 11 12. If you qualify for this credit, enter the number of personal and dependent exemptions reported on your Form 760 (see instructions)...................................................................................................................................12 13. Multiply Line 12 by $300. Enter the result on Line 13. If you do not qualify for the Tax Credit for Low-Income Individuals but claimed the Earned Income Credit on your federal return, enter $0.................................13 14. Enter the amount of Earned Income Credit claimed on your federal return. If you did not claim the Earned Income Credit on your federal return, enter $0.................................................................................................14 15. Multiply Line 14 by 20% (.20)........................................................................................................................................15 16. Enter the greater of Line 13 or Line 15 above...............................................................................................................16 17. Compare the amount on Line 16 above to the amount of tax on Line 18 of Form 760. Enter the lesser of the two amounts here and on Line 23 of Form 760. This is your credit amount.............................................17 . 00 , . 00 , . 00 , . 00 , . 00 , Family VAGI Name Social Security Number Virginia Adjusted Gross Income (VAGI) You Spouse Dependent Dependent 10. Total If more than 4 exemptions, attach schedule listing the name, SSN, & VAGI. Enter total Family VAGI here. loss . 00 , Your Social Security Number - - Use Schedule VAC to make contributions. Credit for Low-Income Individuals or Virginia Earned Income Credit Health Care Coverage Contact Information If you marked the oval on the front of Form 760 to authorize the sharing of information from this return with DMAS and have a preferred contact method, please provide the information below. 22. Indicate your preferred method of contact by filling in the appropriate oval below and providing your information.

Email Email address

Phone Daytime number Mail Provide address if different from the information you provided on page one of your Virginia income tax return. Number and Street City, town, or post office State ZIP Code WEB