Schedule Hi-144 - Vermont Household Income - 2015, Form Pr-141 - Vermont Renter Rebate Claim - 2015 Page 3

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*151411100*

DUE DATE: April 18, 2016 (Claims allowed up to Oct. 17, 2016)

BLUE or BLACK INK

Renter Rebate Claim

2015

FORM

PR-141

* 1 5 1 4 1 1 1 0 0 *

VERMONT

For Household Income of $47,000 or less

For the year Jan. 1–Dec. 31, 2015

Must Be Filed With: Household Income (Schedule HI -144) and Landlord’s Certificate (LC-142)

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 rental property (number, street/road name (Do not use “PO Box,” “same,” or town name)

1. Vermont School District Code

2. City/Town of Legal Residence on Dec . 31, 2015

State

ALL eligibility questions must be answered. You must have rented all 12 months in 2015. See instructions for exception.

Q1. Were you domiciled in Vermont all of calendar year 2015? . . . . . . . . . . . . . .

Yes, Go to Q2 .

No, STOP. You are not eligible .

Q2. Were you claimed as a dependent by another taxpayer in 2015? . . . . . . . . . . .

Yes, STOP. You are not eligible .

No, Go to Q3 .

Q3. Did you rent in Vermont all 12 months in calendar year 2015? . . . . . . . . . . . .

Yes, Complete this form

No, STOP. You are not eligible .

Before doing rebate calculation, complete Household Income (Schedule HI-144).

REBATE CALCULATION

You MUST attach Schedule HI-144 and the LC-142 to this form.

.0 0

3. Allocable Rent (LC-142, Line 16) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. _______________________

4. Home Use. If more than 25% of this rental is used for business, see instructions .

.0 0 %

If no business use, enter 100 .00% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. _______________________

.0 0

5. Allowable Rent for Rebate Claim (Multiply Line 3 by Line 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. ________________________

.0 0

6. Household Income (Schedule HI-144, Line y) If more than $47,000, you are not eligible . . . . . . . 6. _______________________

6a. If Amended Schedule HI-144, Household Income, is attached, check here .

.0 0

7. Maximum Percentage of Income for Rent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. _______________________

If Line 6 Household Income is:

$0 – 9,999

$10,000 – 24,999

$25,000 – 47,000

Enter this % on Line 7:

2.0%

4.5%

5.0%

.0 0

8. Maximum Rent for Household Income (Multiply Line 6 by Line 7 and enter result here) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. ________________________

If Line 8 is more than Line 5, you do not qualify for a renter rebate .

RENTER REBATE AMOUNT

(Subtract Line 8 from Line 5 and enter result here .) If result is zero (0), you do not qualify

.0 0

for a rebate . If filing this form with the Vermont Income Tax Return, also enter this amount on Form IN-111, Line 31d. . . . . è 9. ________________________

MAXIMUM REBATE AMOUNT IS $3,000.

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