Form Hs-122 - Vermont Homestead Declaration And Property Tax Adjustment Claim - 2013

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*141221100*

Homestead Declaration

2014

FORM

AND Property Tax

HS-122

VERMONT

Adjustment Claim

* 1 4 1 2 2 1 1 0 0 *

DUE DATE: April 15, 2014

Please PRINT in BLUE or BLACK INK

This form can be filed on-line at

To file a Homestead Declaration:

Please complete Section A, sign in the signature section at the bottom of page 2 and send to the Department .

To file a Property Tax Adjustment Claim:

Please complete Section A and Section B, sign and send to the Department together with a completed HI-144 Household

Income Schedule . You will not receive a Property Tax Adjustment unless you file a Homestead Declaration, a Property

Tax Adjustment Claim, and a Household Income schedule .

ANNUAL Vermont Homestead Declaration

This form must be filed EACH YEAR by ALL VT residents who own and occupy

SECTION A.

a VT homestead on April 1 even if a claim for property tax adjustment is not made.

Claimant’s Last Name

First Name

Initial

Claimant’s Social Security Number

Spouse or CU Partner Last Name

First Name

Initial

Spouse or CU Partner 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 Homestead (number, street/road name (Do not use “PO Box”, “same”, or Town name)

A1. VT School Code

A2. City/Town of Legal Residence on 04/01/2014

State

A3. SPAN Number - REQUIRED (From the 2013/2014 property tax bill)

.0 0 %

A4. Business Use of Dwelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A4. ________________

.0 0 %

A5. Rental Use of Dwelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A5. ________________

A6. Business or Rental Use of Improvements or Other Buildings

Not including the dwelling, are improvements or other buildings located on your parcel

used for business or rented? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

A7 - A10 Special Situations (see instructions for more information) . Check the following if it applies:

A7. Grantor and sole beneficiary of a

A9. Homestead property crosses town boundaries .

revocable trust owning the property .

(File a declaration for each town .)

A8. Life estate holder of the property .

A10. Residing in a dwelling owned by a related

farmer .

IMPORTANT FILING INFORMATION

Form HS-122, Section B and Schedule HI-144 are required to file a Property Tax Adjustment Claim .

Continue on to complete Section B or