Vermont Form Hi-144 - Household Income - 2004 Page 2
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2*041441299*
Form HI-144, page 2
* 0 4 1 4 4 1 2 9 9 *
1. Claimant
2. Spouse/CU Partner
3. Other Persons
Carried forward from Line n on front page
1. Claimant
2. Spouse/CU Partner
3. Other Persons
o. Social security (W-2 box 4) and Medicare tax (W-2 box 6) withheld on wages included above and/or self-employment tax paid, less any amount
deducted from Federal Form 1040-Line 30. Attach W-2 forms and/or Federal Schedule SE if not included with income tax filing.
_______________________
.
.
.
,
,
,
0 0
0 0
0 0
o.
o.
o.
p. Child support paid. You must attach proof of payment. See instructions.
-
-
$ $
Support paid to ________________________________________________________________________SSN
.
.
.
,
,
,
0 0
0 0
0 0
p.
p.
p.
q. Adjustments to income from Federal Form 1040-Line 35 or 1040A-Line 20
______________________________________________________________________________
.
.
.
,
,
,
0 0
0 0
0 0
q.
q.
q.
r. TOTAL ADJUSTMENTS Add Lines o, p, and q.
___________________________________________________________________________________________________________
.
.
.
,
,
,
0 0
0 0
0 0
r.
r.
r.
s. ADJUSTED INCOMES OF HOUSEHOLD MEMBERS Subtract Line r from Line n.
__________________________________________________________________________
.
.
.
,
,
,
0 0
0 0
0 0
s.
s.
s.
t. TOTAL HOUSEHOLD INCOME Add the totals of Columns 1, 2, and 3 Line s.
______________________________________________________________________________
.
,
0 0
$ $
t.
TOTAL
RENTERS:
If total Household Income is $47,000 or less, enter Line t on Form PR-141, Line 6. File claim by December 1, 2005.
If more than $47,000, you do not qualify for a renter rebate.
HOMEOWNERS:
EDUCATION PAYMENT
Enter Line t as Household Income on Form HS-138, Line 4. File application by December 1, 2005. (Payment availability generally phases out at
$88,000.)
HOMEOWNER REBATE
If total Household Income is $47,000 or less, enter Line t on Form HS-139, Line 16. File claim by December 1, 2005.
If more than $47,000, you do not qualify for a homeowner rebate.
DECLARATION OF VERMONT HOMESTEAD
Remember to file Form HS-131 if you own and occupy the home on April 1, 2005. File declaration by April 15, 2005.
38
Form HI-144
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