Form Hs-122, Schedule Hi-144 - Homestead Declaration And Property Tax Adjustment Claim Page 4
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4*171441200*
Claimant’s Last Name
Social Security Number
* 1 7 1 4 4 1 2 0 0 *
1. Claimant and jointly
2. Filing separately
3. Other Persons
filed Spouse
Spouse or CU Partner
$
$
$
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 claimed on Line d. 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. Include W-2 and/or Federal Schedule SE
.0 0
.0 0
.0 0
if not included with income tax filing. . . . . . . . . .o. ________________________
________________________
________________________
p. Child support paid. You must include 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 -0- . . . . . . . . . . . . . . . s. ________________________
________________________
________________________
.0 0
t. Add all three amounts from Line s. If a negative amount, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . t. ________________________
u. Complete if born Jan. 1, 1953, 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 -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x. ________________________
.0 0
HOUSEHOLD INCOME.
y.
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 17, 2018, but can be filed up to Oct. 15, 2018.
If Household Income is more than $47,000, you do not qualify for a renter rebate.
HOMEOWNERS:
Form HS-122, Homestead Declaration AND Property Tax Adjustment Claim, must be filed each year.
Homeowners with Household Income up to $147,500 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 17, 2018. Homeowners filing a property tax adjustment, Forms HS-122 and HI-144, between
April 18 and Oct. 15, 2018, may still qualify for a property tax adjustment. A $15 late filing fee will be deducted from the adjustment.
5454
Schedule HI-144, page 2 of 2
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