Form Pr-141, Schedule Hi-144 - Renter Rebate Claim - 2017

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*171411100*
DUE DATE: April 17, 2018 (Claims allowed up to Oct. 15, 2018)
BLUE or BLACK INK
Renter Rebate Claim
2017
FORM
PR-141
* 1 7 1 4 1 1 1 0 0 *
VERMONT
For Household Income of $47,000 or less
Must Be Filed With: Household Income (Schedule HI -144) and Landlord’s Certificate (Form LC-142)
For the year Jan. 1–Dec. 31, 2017
Claimant’s Last Name
First Name
Initial
Claimant’s Social Security Number
Spouse’s or CU Partner’s Last Name
First Name
Initial
Spouse’s or CU Partner’s Social Security Number
Mailing Address (Number and Street/Road or PO Box)
Claimant’s Date of Birth (MM DD YYYY)
/
/
City
State
ZIP Code
Federal Filing Status (Single=S; Head
-
of Household=H; Joint=J; Separate=P)
Physical Location of rental property (Use a number, street/road name. Do not use a PO Box or “same .”)
E-file Certificate Number (from LC-142), if available
1. Vermont School District Code
2. City/Town of Legal Residence on Dec . 31, 2017
State
Will you be using Renter Rebate to pay Income
Tax liability?
c
Yes
c
No
ALL eligibility questions must be answered. You must have rented all 12 months in 2017. See instructions for exception.
Q1. Were you domiciled in Vermont all of calendar year 2017? . . . . . . . . . . . . . .
Yes, Go to Q2 .
No, STOP. You are not eligible .
c
c
Q2. Were you claimed as a dependent by another taxpayer in 2017? . . . . . . . . . . .
c
Yes, STOP. You are not eligible .
c
No, Go to Q3 .
Q3. Did you rent in Vermont all 12 months in calendar year 2017? . . . . . . . . . . . .
Yes, Complete this form
No, STOP. You are not eligible .
c
c
Before doing rebate calculation, complete Household Income (Schedule HI-144).
REBATE CALCULATION
You MUST include Schedule HI-144 and Form LC-142 with this form.
.0 0
3. Allocable Rent (from Form LC-142) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. _______________________
4. Home Use. If more than 25% of this rental is used for business, see instructions .
.0 0 %
If no business use, enter 100 .00% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. _______________________
.0 0
5. Allowable Rent for Rebate Claim (Multiply Line 3 by Line 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. ________________________
.0 0
6. Household Income (Schedule HI-144, Line y) If more than $47,000, you are not eligible . . . . . . . 6. _______________________
6a. If Amended Schedule HI-144, Household Income, is included, check here .
c
.0 0
%
7. Maximum Percentage of Income for Rent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. _______________________
If Line 6 Household Income is:
$0 – 9,999
$10,000 – 24,999
$25,000 – 47,000
Enter this % on Line 7:
2.0%
4.5%
5.0%
.0 0
8. Maximum Rent for Household Income (Multiply Line 6 by Line 7 and enter result here) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. ________________________
If Line 8 is more than Line 5, you do not qualify for a renter rebate .
RENTER REBATE AMOUNT
9.
(Subtract Line 8 from Line 5 and enter result here .) If result is zero (0), you do not qualify
.0 0
for a rebate . If using your rebate to pay your Vermont Income Tax liability, also enter this amount on Form IN-111, Line 31d. è 9. ________________________
MAXIMUM REBATE AMOUNT IS $3,000.
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.
Check here if authorizing the Vermont Department of Taxes to discuss this return and attachments with your preparer.
Preparer’s signature
Date
Preparer’s
SSN or
Preparer’s
PTIN
Use Only
Firm’s name (or yours if self-employed) and address
EIN
Preparer’s Telephone Number
5454
Keep a copy for your records.
MAIL TO: Vermont Department of Taxes, PO Box 1881, Montpelier, VT 05601-1881
27
Form PR-141
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