Form 4822 Statement of Annual Personal and Family Expenses

1 Doctors hospitals etc 2 Cable / Satellite Alimony Auto payments (including interest) Barber beauty shop and cosmetics Child support Clothing Credit card payments Education (tuition room board books etc ) EN Home insurance ES Recreation entertainment vacations Example: EXP Repairs and improvements EXPEN Insurance Expense Remarks Form 4822 VT Groceries and outside meals HO Cell phone HO Property taxes I certify that the above is accurate to the best of my knowledge and belief Internet ITEM EXPENSE TOTAL REMARKS L EXPE Gifts and allowances Laundry and dry cleaning LD Child care Life and accident insurance Mortgage payments (including interest) NA Federal taxes (income FICA etc ) Name Social Security Number Calendar Year Dept Use Only NS Dues (clubs lodge etc ) Other loan payments PE Prescription medications Rent $7 000 $1 000 from last year s renter rebate; $4 000 from salary; $2 000 student loan RSO Medical insurance S Gasoline oil grease wash SE Tires batteries repairs registration SES Domestic help Signature Date Daytime Telephone Number TO Lease of auto USE Income taxes (Federal and State) Utilities (electricity gas telephone water etc ) Vermont Department of Taxes 133 State Street Montpelier VT 05633 1401 Phone: (866) 828 2865 VERMONT STATEMENT OF ANNUAL ESTIMATED PERSONAL AND FAMILY EXPENSES FORM 4822 VT