Form 8879-Vt - Individual Income Tax Declaration For Electronic Filing - 2014
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12014
VERMONT
For office use only
Individual Income Tax Declaration for Electronic Filing
Date received
(SEE INSTRUCTIONS IN THE VT FED/STATE E-FILE HANDBOOK)
Form 8879-VT
Part I
Last Name
First Name and Initial
Enter Social Security Number (SSN)
-
-
Spouse’s Last Name (if different and joint return)
First Name and Initial
Enter Spouse’s SSN, if joint return
Remember
-
-
to write in
your Social
Current Mailing Address
E-mail Address
Security
Number
City or Town
State
Zip Code
Telephone Number
(
)
Part II Tax Return Information (whole dollars only)
1.
Federal Taxable Income (Form IN-111, Section 3, Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1. _____________________
2. Vermont Taxable Income (Form IN-111, Section 3, Line 15) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2. _____________________
3. Adjusted VT Income Tax (Form IN-111, Section 4, Line 22) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. _____________________
4. Vermont Income Tax Withheld (Form IN-111, Section 7, Line 31a) . . . . . . . . . . . . . . . . . . . . . . . . . . .4. _____________________
5. Vermont Earned Income Tax Credit (Form IN-111, Section 7, Line 31c) . . . . . . . . . . . . . . . . . . . . . . . .5. _____________________
6. Refund credited to 2015 estimated tax (Form IN-111, Section 8, Line 33a) . . . . . . . . . . . . . . . . . . . . . .6. _____________________
7. Refund credited to 2015 property tax bill (Form IN-111, Section 8, Line 33b) . . . . . . . . . . . . . . . . . . .7. _____________________
8.
Refund Amount (Form IN-111, Section 8, Line 34)
(check applicable box)
Amount Due (Form IN-111, Section 9, Line 37) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8. _____________________
DO NOT MAIL THIS FORM
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-- KEEP THIS FORM AND REQUIRED ATTACHMENTS ON FILE FOR 3 YEARS
Part III Form HS-122 For Vermont Residents Only (check box)
Check here if Property Tax Adjustment Claim filed
Part IV
Direct Deposit of Refund
ACH Debit Payment Amount $____________ Payment Date ____/____/2015
Routing transit number (RTN)
The first two numbers of the RTN must be 01 through 12 or 21 through 32.
Depositor account number (DAN)
Type of account:
Checking
Savings
Part V Declaration of Taxpayer
By signing below, you agree that:
•
Under penalties of perjury, I declare the information I provided to my Electronic Return Originator (ERO) and the amounts shown in Part II agree
with the amounts shown on the corresponding lines of my 2014 Vermont Individual Income tax return and is, to the best of my knowledge and
belief, true, accurate and complete.
•
If making an ACH Debit Payment, I authorize the Department to withdraw funds from my account in the amount and on the date specified.
•
I consent to have the ERO forward my return, including this declaration and accompanying schedules and statements, to the Vermont Department
of Taxes upon the Department’s request.
•
If the Vermont Department of Taxes does not receive full and timely payment of the amount due, I am liable for the tax and any applicable charges.
Please Sign
Here
Your Signature
Date
Spouse’s Signature (if joint return, BOTH must sign)
Date
Part VI Declaration of Electronic Return Originator (ERO) Only
As an ERO, I am not responsible for review of the taxpayer’s return but declare this form accurately reflects the data on the return. The taxpayer(s)
signed this form before I submitted the return. I will give the taxpayer a copy of all forms and information to be filed with Vermont.
ERO’s
Electronic
Date
Check if:
paid preparer
signature
self-employed
Return
EIN
Originator’s
Firm’s name (or
yours if
Use Only
Phone Number
self-employed)
and address
E-mail address:
Part VII Declaration of Paid Preparer
Under penalties of perjury, I declare that I have examined the above taxpayer’s return and accompanying schedules and statement. To the best of my
knowledge and belief, they are true, correct and complete. This declaration is based on all information of which I have knowledge.
Date
Check if
Preparer’s
self-employed
Paid
signature
Preparer’s
EIN
Firm’s name (or
Use Only
yours if
Phone Number
self-employed)
and address
E-mail address:
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