Form Hs-122w - Vermont Homestead Declaration And/or Property Tax Adjustment Withdrawal

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Vermont Department of Taxes
Telephone: (802) 828-2865
Taxpayer Services Division
(866) 828-2865
PO Box 1645
Fax:
(802) 828-2720
Montpelier, VT 05601-1645
E-mail:
tax.individualincome@vermont.gov
Vermont Homestead Declaration and/or Property Tax Adjustment
FORM
HS-122W
WITHDRAWAL
Declarant’s Last Name
Declarant’s First Name and Initial
Declarant’s SSN
_
_
Spouse’s/CU Partner’s Last Name
Spouse’s/CU Partner’s First Name and Initial
Spouse’s/CU Partner’s SSN
_
_
Current Mailing Address
City or Town
State
Zip Code
SPAN (School Property Account Number on tax bill)
PHYSICAL LOCATION of property (number and street, road, or route name)
Date that Form HS-122 was filed
PROPERTY
BEING
WITHDRAWN
PROPERTY SALES AND CHANGES AFTER FILING A 2016 DECLARATION OF VERMONT HOMESTEAD
AND/OR PROPERTY TAX ADJUSTMENT CLAIM
A 2016 Vermont Homestead Declaration and Property Tax Adjustment claim requires the property owner as of
April 1, 2016, to occupy the property as his/her domicile. If your homestead is leased to a tenant on April 1, 2016,
it may still be declared a homestead if it is not leased for more than 182 days in the 2016 calendar year. Use this
form to withdraw a Declaration and/or Property Tax Adjustment claim if one of the following events occur:
Property sold on or before April 1, 2016. Name of Buyer _______________________
Date sold ____________________________
Property was rented on April 1, 2016, and leased for more than 182 days in 2016.
Property converted to non-homestead before April 1, 2016.
Declaration submitted in error. The property was not my principal residence on April 1, 2016.
Claimant of the Property Tax Adjustment died before April 1, 2016.
Estates may claim homestead for purpose of homestead property tax provided the property is not rented.
Other. Please explain. __________________________________________________________________
____________________________________________________________________________________
I am hereby withdrawing my Homestead Declaration and/or Property Adjustment as described above.
Declarant’s Signature
Date
Telephone Number
Check here if authorizing the Vermont Department of Taxes to discuss this return and attachments with your preparer.
Paid preparer’s use only.
Preparer’s Signature
Date
Preparer’s Telephone Number
Preparer’s EIN/SSN/PTIN
Form HS-122W
Rev. 12/15

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