Schedule Hi-144 - Vermont Household Income - 2015, Form Hs-122 - Vermont Homestead Declaration And Property Tax Adjustment Claim - 2016 Page 3

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Homestead Declaration

*161221100*

2016

FORM

AND Property Tax

HS-122

VERMONT

Adjustment Claim

* 1 6 1 2 2 1 1 0 0 *

DUE DATE: April 18, 2016. You must file your Homestead Declaration by the due date even if you have filed an extension for your personal

income tax.

Please PRINT in BLUE or BLACK INK

This form can be filed online at

To file a Homestead Declaration:

Please complete Section A, sign in the signature section at the bottom of page 2 and send to the Department .

To file a Property Tax Adjustment Claim:

Please complete Section A and Section B, sign and send to the Department together with a completed

HI-144, Household Income Schedule . You will not receive a Property Tax Adjustment unless you file a

Homestead Declaration, a Property Tax Adjustment Claim, and a Household Income schedule .

Annual Vermont Homestead Declaration

This form must be filed each year by every Vermont resident whose property meets the definition of a homestead.

SECTION A.

A Vermont homestead is the principal dwelling and parcel of land surrounding the dwelling, owned and occupied by

a resident individual as the individual’s domicile on April 1. If your homestead is leased to a tenant on April 1, you

may still claim it as a homestead if it is not leased for more than 182 days in the 2016 calendar year.

Claimant’s Last Name

First Name

Initial

Claimant’s Social Security Number

Spouse’s or CU Partner’s Last Name

First Name

Initial

Spouse’s or CU Partner’s Social Security Number

Mailing Address (Number and Street/Road or PO Box)

Claimant’s Date of Birth (MM DD YYYY)

City

State

ZIP Code

Location of Homestead (number, street/road name (Do not use “PO Box,” “same,” or town name)

A1. Vermont School District Code

A2. City/Town of Legal Residence on April 1, 2016

State

A3. SPAN Number - REQUIRED (From the 2015/2016 property tax bill)

.0 0 %

A4. Business Use of Dwelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A4. ________________

.0 0 %

A5. Rental Use of Dwelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A5. ________________

A6. Business or Rental Use of Improvements or Other Buildings

Not including the dwelling, are improvements or other buildings located on your parcel

used for business or rented? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

A7 - A10 Special Situations (see instructions for more information) . Check the following if it applies:

A7. Grantor and sole beneficiary of a

A9. Homestead property crosses town boundaries .

revocable trust owning the property .

(File a declaration for each town .)

A8. Life estate holder of the property .

A10. Residing in a dwelling owned by a related farmer .

IMPORTANT FILING INFORMATION

Form HS-122, Section B and Schedule HI-144 are required to file a Property Tax Adjustment Claim .

Continue on to complete Section B .

If you will not be filing a Property Tax Adjustment Claim, please sign in the signature section at the