Form In-116 - Vermont Income Tax Payment Voucher - 2012
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1Use this form if NOT submitting
*121161199*
payment with Form IN-111.
Income Tax
2012
FORM
* 1 2 1 1 6 1 1 9 9 *
116
IN-
Payment Voucher
VERMONT
Spouse or CU Partner
Taxpayer’s Social
Social Security Number
Security Number
Taxpayer’s
First
Initial
Last Name
Name
Spouse or
First
CU Partner
Initial
Name
Last Name
Mailing Address
(Number and Street/
Road or PO Box)
-
ZIP
City/Town
State
Code
If you electronically filed, DO NOT include a copy of the filed return with this payment.
5454
.
0 0
Amount of this payment $
Mail to: VT Department of Taxes
PO Box 1779
Form IN-116
Montpelier, VT 05601-1779
(Rev. 10/12)
Make check payable to: VERMONT DEPARTMENT OF TAXES
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