*151441100*
2015
If filing HS-122 only,
SCHEDULE
Household Income
HI-144
click here to go to
VERMONT
HS-122, Section A.
* 1 5 1 4 4 1 1 0 0 *
For the year Jan. 1– Dec. 31, 2015
CHECK IF AMENDING
FORM HS-122 OR
FORM PR-141
c
c
Please PRINT in BLUE or BLACK INK
This schedule must be attached to the 2015 Renter Rebate Claim (Form PR-141) OR the 2016 Property Tax Adjustment Claim (Form HS-122)
UNLESS you are filing an AMENDED HI-144. Please read instructions before completing schedule.
Claimant’s Last Name
First Name
Initial
Claimant’s Social Security Number
Enter name(s), SSN(s),
and Date of Birth on
Spouse’s or CU Partner’s Last Name
First Name
Initial
Claimant’s Date of Birth
Form HS-122.
/
/
List the names and Social Security Numbers of all other persons (other than a Spouse or CU Partner) who had income and lived with you during 2015. Include their
income in Column 3. If you have more than two “Other Persons” living in your household, record the names and Social Security Numbers on a separate sheet of paper
and include with the filing.
Other Person #1 Last Name
First Name
Initial
Other Person #1 Social Security Number
Other Person #2 Last Name
Other Person #2 Social Security Number
First Name
Initial
Yearly totals of ALL
1. Claimant
2. Spouse/CU Partner
3. Other Persons
members of the household
.0 0
.0 0
.0 0
a. Cash public assistance and relief . . . . . . . . . . a. _________________________
________________________
________________________
b. Social security, SSI, disability, railroad
retirement,veteran’s benefits,
.0 0
.0 0
.0 0
taxable and nontaxable . . . . . . . . . . . . . . . . b. _________________________
________________________
________________________
c. Unemployment compensation/worker’s
.0 0
.0 0
.0 0
compensation . . . . . . . . . . . . . . . . . . . . . . . . . c. _________________________
________________________
________________________
d. Wages, salaries, tips, etc . (See instructions
.0 0
.0 0
.0 0
for dependent’s exempt income .) . . . . . . . . . . d. _________________________
________________________
________________________
.0 0
.0 0
.0 0
e. Interest and dividends . . . . . . . . . . . . . . . . . . . e. _________________________
________________________
________________________
f. Interest on U .S ., state, and municipal
.0 0
.0 0
.0 0
obligations, taxable and nontaxable . . . . . . . .f. _________________________
________________________
________________________
g. Alimony, support money, child support,
.0 0
.0 0
.0 0
cash gifts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . g. _________________________
________________________
________________________
h. Business income . If the amount is a loss,
enter zero. See instructions for
.0 0
.0 0
.0 0
offsetting a loss. . . . . . . . . . . . . . . . . . . . . . . . h. _________________________
________________________
________________________
i. Capital gains, taxable and nontaxable.
If the amount is a loss, enter zero (0).
.0 0
.0 0
.0 0
See instructions for offsetting a loss. . . . . . . .i. _________________________
________________________
________________________
j. Taxable pensions, annuities, IRA and other
retirement fund distributions .
.0 0
.0 0
.0 0
See instructions. . . . . . . . . . . . . . . . . . . . . . . .j. _________________________
________________________
________________________
k. Rental and royalty income . If the amount
is a loss, enter zero. See instructions for
.0 0
.0 0
.0 0
offsetting a loss. . . . . . . . . . . . . . . . . . . . . . . . k. _________________________
________________________
________________________
l. Farm/partnerships/S corporations/LLC/
Estate or Trust income . If the amount is a
loss, enter zero. See Line i instructions
.0 0
.0 0
.0 0
for only exception to offset a loss. . . . . . . . . .l. _________________________
________________________
________________________
m. Other income (See instructions for examples
of other income) .
.0 0
.0 0
.0 0
Please specify . ___________________ . . . . .m. _________________________
________________________
________________________
.0 0
.0 0
.0 0
n. Total Income: Add Lines a through m . . . . . n. _________________________
________________________
________________________
5454
continued on back
Schedule HI-144