Form Hs-122 - Vermont Homestead Declaration And Property Tax Adjustment Claim - 2013 Page 2

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*141221200*

Form HS-122, page 2 of 2

* 1 4 1 2 2 1 2 0 0 *

DUE DATE: April 15, 2014

PROPERTY TAX ADJUSTMENT CLAIM

SECTION B.

For Household Income up to approx. $105,000. Attach Schedule HI-144

ALL eligibility questions must be answered.

You must own and occupy the property as your primary home on April 1, 2014.

B1. Were you domiciled in VT all of calendar year 2013? . . . . . . . . . . . . . . . . .

Yes, Go to Line B2.

No, STOP

B2. Were you claimed as a dependent in 2013 by another taxpayer? . . . . . . . . .

Yes, STOP

No, Go to Line B3.

B3. Do you anticipate selling your VT housesite on or before April 1, 2014? . .

Yes, STOP

No, CONTINUE

Amounts for Lines B4 - B6 are found on the 2013/2014 property tax bill. Round amounts to the nearest dollar.

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B4. Housesite Value . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B4.____________________

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B5. Housesite Education Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B5.____________________

.0 0

B6. Housesite Municipal Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B6.____________________

.0 0 %

B7. Ownership Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B7.____________________

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B8. Household Income (Schedule HI-144, Line y) . Schedule HI-144 MUST be attached. . . . . . . . . . . B8.____________________

B8a. If AMENDED SCHEDULE HI-144, Household Income, is attached, check here .

Complete the following ONLY if applicable. See instructions on page 41 for details .

Lot Rent

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B9. Mobile Home Lot Rent (Form LC-142, Line 16 - attach Form to this claim) . . . . . . . . . . . . . . . . . . . B9.____________________

OR Allocated Property Tax from Land Trust, Cooperative, or Nonprofit Mobile Home Park

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B10. Allocated Education Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B10.____________________

.0 0

B11. Allocated Municipal Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B11.____________________

OR Property Tax from contiguous property if housesite has less than 2 acres (see instructions) .

.0 0

B12. Contiguous property Education Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B12.____________________

.0 0

B13. Contiguous property Municipal Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B13.____________________

MAXIMUM ADJUSTMENT AMOUNT IS $8,000.

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 VT Department of Taxes to discuss this return and attachments with your preparer.

Preparer’s signature

Date

Preparer’s