Form 4822-Vt - Statement Of Annual Estimated Personal And Family Expenses

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Vermont Department of Taxes
133 State Street
Montpelier, VT 05633-1401
Phone: (866) 828-2865
STATEMENT OF ANNUAL ESTIMATED
F
ORM
V
ERMONT
4822-VT
PERSONAL AND FAMILY EXPENSES
Name
Social Security Number
Calendar Year
Dept. Use Only
ITEM
EXPENSE TOTAL
REMARKS
Groceries and outside meals
Clothing
Laundry and dry cleaning
Barber, beauty shop, and cosmetics
Education (tuition, room, board, books, etc.)
Recreation, entertainment, vacations
Dues (clubs, lodge, etc.)
Gifts and allowances
Life and accident insurance
Federal taxes (income, FICA, etc.)
Medical insurance
Prescription medications
Doctors, hospitals, etc.
Alimony
Child support
Credit card payments
Other loan payments
Rent
Mortgage payments (including interest)
Utilities (electricity, gas, telephone, water, etc.)
Domestic help
Home insurance
Repairs and improvements
Child care
Property taxes
Income taxes (Federal and State)
Cell phone
Cable / Satellite
Internet
Gasoline, oil, grease, wash
Tires, batteries, repairs, registration
Insurance
Auto payments (including interest)
Lease of auto
I certify that the above is accurate to the best of my knowledge and belief.
Signature
Date
Daytime Telephone Number
Form 4822-VT
9/09

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