Vermont Form Hi-144 - Household Income - 2004

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*041441199*
FORM
2004
Household Income
HI-144
VERMONT
* 0 4 1 4 4 1 1 9 9 *
For the year Jan. 1– Dec. 31, 2004
DUE DATE: December 1, 2005 • PRINT in BLUE or BLACK INK
This form must be attached to Renter Rebate Claim OR Homeowner Property Tax Rebate Claim OR
2005 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 2004. 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.)
______________________________________________________________________
.
.
.
,
,
,
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
37
Form HI-144

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