Schedule Hi-144 - Vermont Household Income - 2015, Form Hs-122 - Vermont Homestead Declaration And Property Tax Adjustment Claim - 2016 Page 4
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1
2
3
4Claimant’s Last Name
Social Security Number
*161221200*
* 1 6 1 2 2 1 2 0 0 *
DUE DATE: April 18, 2016. Claims accepted up to Oct. 17, 2016.
PROPERTY TAX ADJUSTMENT CLAIM
SECTION B.
For Household Income up to $137,500. Attach Schedule HI-144
To qualify, you must meet the requirements for filing a homestead declaration in addition to the following requirements.
ALL eligibility questions must be answered.
B1. Were you domiciled in Vermont all of calendar year 2015? . . . . . . . . . . . . . . .
Yes, Go to Line B2.
No, STOP
c
c
B2. Were you claimed as a dependent in 2015 by another taxpayer? . . . . . . . . . . . .
Yes, STOP
No, Go to Line B3.
c
c
B3. Do you anticipate selling your Vermont housesite on or before April 1, 2016? .
Yes, STOP
No, CONTINUE
c
c
Amounts for Lines B4 - B6 are found on the 2015/2016 property tax bill. Round amounts to the nearest dollar.
.0 0
B4. Housesite Value . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B4.____________________
.0 0
B5. Housesite Education Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B5.____________________
.0 0
B6. Housesite Municipal Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B6.____________________
.0 0 %
B7. Ownership Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B7.____________________
.0 0
B8. Household Income (Schedule HI-144, Line y) . Schedule HI-144 MUST be attached. . . . . . . . . . . B8.____________________
B8a. If Amended Schedule HI-144, Household Income, is attached, check here .
c
Complete the following ONLY if applicable. See instructions for details .
Lot Rent
.0 0
B9. Mobile Home Lot Rent (Form LC-142, Line 16 - attach Form to this claim) . . . . . . . . . . . . . . . . . . . B9.____________________
OR Allocated Property Tax from Land Trust, Cooperative, or Nonprofit Mobile Home Park
.0 0
B10. Allocated Education Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B10.____________________
.0 0
B11. Allocated Municipal Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B11.____________________
OR Property Tax from contiguous property if housesite has less than 2 acres (see instructions) .
.0 0
B12. Contiguous property Education Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B12.____________________
.0 0
B13. Contiguous property Municipal Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B13.____________________
MAXIMUM ADJUSTMENT AMOUNT IS $8,000.
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge
and belief, they are true, correct and complete . Preparers cannot use return information for purposes other than preparing returns .
Signature
Date
Telephone Number
Signature. If a joint return, BOTH must sign.
Date
Check here if authorizing the Vermont Department of Taxes to discuss this return and attachments with your preparer.
Preparer’s signature
Date
Preparer’s
SSN or
Preparer’s
PTIN
Use Only
Firm’s name (or yours if self-employed) and address
EIN
Preparer’s Telephone Number
5454
Mail to: Vermont Department of Taxes
PO Box 1881
Montpelier, VT 05601-1881
Form HS-122, page 2 of 2
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