Schedule Hi-144 - Vermont Household Income - 2013 Page 2
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2*131441200*
Schedule HI-144, page 2 of 2
* 1 3 1 4 4 1 2 0 0 *
1. Claimant
2. Spouse/CU Partner
3. Other Persons
$
$
$
1. Amount from Line n, Column 1
2. Amount from Line n, Column 2
3. Amount from Line n, Column 3
o. See instructions Enter Social Security and Medicare
tax withheld on wages . Self-Employed: Enter self-
employment tax from Federal Schedule SE . This
entry may differ from W-2/1099 or Federal Schedule
SE amount if these taxes are paid on income not
required to be reported on Schedule HI-144 .
Attach W-2 and/or Federal Schedule SE if not
.0 0
.0 0
.0 0
included with income tax filing . . . . . . . . . . . . . . .o. ________________________
________________________
________________________
p. Child support paid . You must attach proof
.0 0
.0 0
.0 0
of payment . See instructions . . . . . . . . . . . . . . . . p. ________________________
________________________
________________________
Support paid to: Last Name
First Name
Initial
Social Security Number
q. Allowable Adjustments from Federal Form 1040 or 1040A
q1. Business Expenses for Reservists
.0 0
.0 0
.0 0
(1040, Line 24) . . . . . . . . . . . . . . . . . . q1. ________________________
________________________
________________________
.0 0
.0 0
.0 0
q2. Alimony paid (1040, Line 31a) . . . . . . q2. ________________________
________________________
________________________
q3. Tuition and Fees (1040, Line 34 or
.0 0
.0 0
.0 0
1040A, Line 19) . . . . . . . . . . . . . . . . . q3. ________________________
________________________
________________________
q4. Self-employed health insurance
.0 0
.0 0
.0 0
deduction (1040, Line 29) . . . . . . . . . . q4. ________________________
________________________
________________________
q5. Health Savings account deduction
.0 0
.0 0
.0 0
(1040, Line 25) . . . . . . . . . . . . . . . . . . q5. ________________________
________________________
________________________
r. Add Lines o, p and total of Lines q1 to q5 for
.0 0
.0 0
.0 0
each column . . . . . . . . . . . . . . . . . . . . . . . . . . . . .r. ________________________
________________________
________________________
s. Subtract Line r from Line n of each column .
.0 0
.0 0
.0 0
If a negative amount, enter zero (0) . . . . . . . . . . . s. ________________________
________________________
________________________
.0 0
t. Add all three amounts from Line s . If a negative amount, enter zero (0) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . t. ________________________
u. Complete if born 1/1/1949 and after .
Enter interest and dividend income from
.0 0
.0 0
.0 0
Lines e and f . . . . . . . . . . . . . . . . . . . . . . . . . . . . u. ________________________
________________________
________________________
.0 0
v. Add all three amounts from Line u . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v. ________________________
10000.0 0
w. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . w. ________________________
.0 0
x. Subtract Line w from Line v . If Line w is more than Line v, enter zero (0) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x. ________________________
.0 0
y. HOUSEHOLD INCOME. Add Line t and Line x . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . y. ________________________
RENTERS:
If Line y Household Income is $47,000 or less, you may be eligible for a renter rebate . Complete Form PR-141 . This schedule must
be filed with the Renter Rebate Claim . Claims are due April 15, 2014 but can be filed up to October 15, 2014 .
If Household Income is more than $47,000, you do not qualify for a renter rebate .
HOMEOWNERS:
Form HS-122 , Property Tax Adjustment Claim, must be filed each year .
Homeowners with Household Income up to $105,000 on Line y should complete Form HS-122, Section B. You may be eligible for
a property tax adjustment . This schedule must be filed with the HS-122 .
Form HS-122 Due Date - April 15, 2014. Homeowners filing a completed HS-122 and HI-144 between April 16 and October 15,
2014 may still qualify for a property tax adjustment . A $15 late filing fee will be deducted from the adjustment .
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Schedule HI-144
5454
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