Form Pr-141, Schedule Hi-144 - Renter Rebate Claim - 2017 Page 2
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3*171441100*
2017
SCHEDULE
Household Income
HI-144
VERMONT
* 1 7 1 4 4 1 1 0 0 *
For the year Jan. 1–Dec. 31, 2017
CHECK IF AMENDING
FORM HS-122 OR
FORM PR-141
c
c
Please PRINT in BLUE or BLACK INK
This schedule must be included with the 2017 Renter Rebate Claim (Form PR-141) OR the 2018 Property Tax Adjustment Claim (Form
HS-122) UNLESS you are filing an AMENDED HI-144. Please read instructions before completing schedule.
Claimant’s Last Name
First Name
Initial
Claimant’s Social Security Number
Spouse’s or CU Partner’s Last Name
First Name
Initial
Claimant’s Date of Birth
/
/
List the names and Social Security Numbers of all other persons (other than a Spouse or CU Partner) who had income and lived with you during 2017. Include their
taxable and non-taxable income in Column 3. If you have more than two “Other Persons” living in your household, record the names and Social Security Numbers on
a separate sheet of paper and include with the filing.
Other Person #1 Last Name
First Name
Initial
Other Person #1 Social Security Number
Other Person #2 Last Name
First Name
Initial
Other Person #2 Social Security Number
1. Claimant and jointly
2. Filing separately
Totals of ALL
3. Other Persons
filed spouse
Spouse or CU Partner
members of the household
.0 0
.0 0
.0 0
a. Cash public assistance and relief . . . . . . . . . . a. _________________________
________________________
________________________
b. Social Security, SSI, disability, railroad
retirement,veteran’s benefits,
.0 0
.0 0
.0 0
taxable and nontaxable . . . . . . . . . . . . . . . . b. _________________________
________________________
________________________
c. Unemployment compensation/worker’s
.0 0
.0 0
.0 0
compensation . . . . . . . . . . . . . . . . . . . . . . . . . c. _________________________
________________________
________________________
d. Wages, salaries, tips, etc . (See instructions
.0 0
.0 0
.0 0
for dependent’s exempt income .) . . . . . . . . . . d. _________________________
________________________
________________________
.0 0
.0 0
.0 0
e. Interest and dividends . . . . . . . . . . . . . . . . . . . e. _________________________
________________________
________________________
f. Interest on U .S ., state, and municipal
.0 0
.0 0
.0 0
obligations, taxable and nontaxable . . . . . . . .f. _________________________
________________________
________________________
g. Alimony, support money, child support,
.0 0
.0 0
.0 0
cash gifts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . g. _________________________
________________________
________________________
h. Business income . If the amount is a loss,
enter -0-. See instructions for
.0 0
.0 0
.0 0
offsetting a loss. . . . . . . . . . . . . . . . . . . . . . . . h. _________________________
________________________
________________________
i. Capital gains, taxable and nontaxable.
If the amount is a loss, enter -0-.
.0 0
.0 0
.0 0
See instructions for offsetting a loss. . . . . . . .i. _________________________
________________________
________________________
j. Taxable pensions, annuities, IRA and other
retirement fund distributions .
.0 0
.0 0
.0 0
See instructions. . . . . . . . . . . . . . . . . . . . . . . .j. _________________________
________________________
________________________
k. Rental and royalty income . If the amount
is a loss, enter -0-. See instructions for
.0 0
.0 0
.0 0
offsetting a loss. . . . . . . . . . . . . . . . . . . . . . . . k. _________________________
________________________
________________________
l. Farm/partnerships/S corporations/LLC/
Estate or Trust income . If the amount is a
loss, enter -0-. See Line i instructions
.0 0
.0 0
.0 0
for only exception to offset a loss. . . . . . . . . .l. _________________________
________________________
________________________
m. Other income (See instructions for examples
of other income) .
.0 0
.0 0
.0 0
Please specify . ___________________ . . . . .m. _________________________
________________________
________________________
.0 0
.0 0
.0 0
n. Total Income: Add Lines a through m . . . . . n. _________________________
________________________
________________________
5454
continued on back
31
Schedule HI-144
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