Form Hs-122w - Vermont Homestead Declaration And/or Property Tax Adjustment Withdrawal
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1Vermont Department of Taxes
Telephone: (802) 828-2865
Taxpayer Services Division
(866) 828-2865 (In State)
PO Box 1645
Fax:
(802) 828-2720
Montpelier, VT 05601-1645
E-mail: schooltax@state.vt.us
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WITHDRAWN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 DECLARATION OF VT HOMESTEAD
AND PROPERTY TAX ADJUSTMENT CLAIM
A Vermont Homestead Declaration and Property Tax Adjustment claim requires the property owner to use the
property as his or her principal residence on April 1. 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. Name of Buyer __________________________.
Property converted to Non Homestead before April 1.
Declaration submitted in error. The property is not my principal residence.
Claimant of the Property Tax Adjustment died before April 1.
• Estates may claim homestead for purpose of homestead property tax provided the property is not rented.
Other. Please explain. __________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
I am hereby withdrawing the above..
DECLARANT’S SIGNATURE
DATE
SPOUSE’S OR CU PARTNER’S SIGNATURE
DATE
Check here if authorizing the VT 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. 11/12
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