Form Hs-122w - Withdrawal - Vermont Homestead Declaration
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1VT DEPARTMENT OF TAXES
Ph: (866) 828-2865 (toll-free in VT)
PO Box 1645
Ph: (802) 828-2865 (local or out-of-state)
Montpelier, VT 05601-1645
Fax: (802) 828-2720
Vermont Homestead Declaration
FORM
HS-122W
WITHDRAWAL
Declarant’s Last Name
Declarant’s First Name and Initial
Declarant’s Social Security Number (SSN)
_
_
Spouse’s/CU Partner’s Last Name (if different and joint return)
First Name and Initial
Enter Spouse’s/CU Partner’s SSN, if joint return
_
_
Current Mailing Address
City or Town
State
Zip Code
SPAN (School Property Account Number on tax bill)
PHYSICAL LOCATION of property (number and street, road, or route name)
DATE that Form HS-122 was filed
PROPERTY
BEING
WITHDRAWN
PROPERTY SALES AND CHANGES AFTER FILING A DECLARATION OF VT HOMESTEAD
A Declaration of Vermont Homestead requires the property owner use the property as his or her principal residence on
April 1. Use this form to withdraw a declaration if one of the following events occur (check one):
Property sold on or before April 1.
Property converted to nonresidential use on or before April 1.
Owner of property died on or before April 1.
Declaration submitted in error. The property is not my principal residence.
Other. Please explain. ___________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
I filed a homestead declaration for the property identified above. Because the property was not my homestead on April 1, I am hereby
withdrawing that declaration.
DECLARANT’S SIGNATURE
DATE
SPOUSE’S OR CU PARTNER’S SIGNATURE
DATE
Check here if authorizing the VT Department of Taxes to discuss this return and attachments with your preparer.
Paid preparer’s use only.
PREPARER’S EIN/SSN/PTIN
PREPARER’S SIGNATURE
DATE
Preparer’s Telephone Number
Form HS-122W
Rev. 1/07
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