Vermont Form Hi-144 - Household Income - 2003
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1
2*031441199*
2003
FORM
Household Income
HI-144
VERMONT
* 0 3 1 4 4 1 1 9 9 *
For the year Jan. 1–Dec. 31, 2003
DUE DATE: December 1, 2004 • PRINT in BLUE or BLACK INK
This form must be attached to Renter Rebate Claim OR Homeowner Property Tax Rebate Claim OR 2004 Education Property Tax
Payment Application .
Read instructions before completing form.
Claimant’s Social Security Number
-
-
Claimant’s Last Name
First Name
Initial
Spouse or CU Partner Social Security Number
Spouse or CU Partner Last Name
First Name
Initial
-
-
List the names and social security numbers of all other persons who had income and lived with you during 2003. Include their income in column 3. Use a separate sheet of paper if needed.
1. _________________________________________________________________________
2. ______________________________________________________________________
1. Claimant
2. Spouse/CU Partner
3. Other Persons
a. Cash public assistance/welfare
______________________________________________________________________________________________________________________
0 0
0 0
0 0
.
.
.
,
,
,
a.
a.
a.
b. Social security/railroad retirement/veteran’s benefits, taxable and nontaxable
____________________________________________________________________
0 0
0 0
0 0
.
.
.
,
,
,
b.
b.
b.
c. Unemployment compensation/worker’s compensation
_______________________________________________________________________________________________
0 0
0 0
0 0
.
.
.
,
,
,
c.
c.
c.
d. Wages, salaries, tips, etc. (See instructions for reportable dependent’s income.)
______________________________________________________________________
N N E E W W
0 0
0 0
0 0
.
.
.
,
,
,
d.
d.
d.
e. Interest and dividends
________________________________________________________________________________________________________________________________
0 0
0 0
0 0
.
.
.
,
,
,
e.
e.
e.
f. Interest on U.S., state, and municipal obligations, taxable and nontaxable
__________________________________________________________________________
0 0
0 0
0 0
.
.
.
,
,
,
f.
f.
f.
g. Alimony, support money, child support
________________________________________________________________________________________________________________
0 0
0 0
0 0
.
.
.
,
,
,
g.
g.
g.
h. Business income: If the amount is a loss, enter zero. See instructions for offsetting a loss.
____________________________________________________
0 0
0 0
0 0
.
.
.
,
,
,
h.
h.
h.
i. Capital gains, taxable and nontaxable. If the amount is a loss, enter zero. See instructions for offsetting a loss.
_____________________________
0 0
0 0
0 0
.
.
.
,
,
,
i.
i.
i.
j. Pensions, annuities, retirement fund distributions. See instructions.
________________________________________________________________________________
0 0
0 0
0 0
.
.
.
,
,
,
j.
j.
j.
k. Rental income: If the amount is a loss, enter zero. See instructions for offsetting a loss.
_______________________________________________________
0 0
0 0
0 0
.
.
.
,
,
,
k.
k.
k.
l. Farm/partnerships/S Corporations/LLCs Income: If the amount is a loss, enter zero. See instructions for offsetting a loss.
___________________
0 0
0 0
0 0
.
.
.
,
,
,
l.
l.
l.
m. Other income. Please specify _______________________________________________________
___________________________________________________
0 0
0 0
0 0
.
.
.
,
,
,
m.
m.
m.
n. TOTAL INCOME: Add Lines a through m
__________________________________________________________________________________________________________
0 0
0 0
0 0
.
.
.
,
,
,
n.
n.
n.
continued on back
Form HI-144
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