Form HS-122-HI-144 Fillable Homestead Declaration & Property Tax Adjustment Claim
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

00 % A5 Rental Use of Dwelling A5 (: HS 122) Unchecked (: No) Unchecked (: No) Unchecked (: No) Unchecked (: PR 141) Unchecked (: Yes) Unchecked (: Yes) Unchecked (: Yes) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (Clear ALL data fields) Clear ALL fields (Click here for printing instructions) Important Printing Instructions (Enter just the 9 digits no hyphens or spaces) (Enter just the 9 digits no hyphens or spaces) (Enter just the 9 digits no hyphens or spaces) (Enter the 2 digit day) (Enter the 2 digit month) (Enter the 3 digit School Code) (Enter the 4 digit year) (Enter the 4 digit ZIP Code extension) (Enter the 5 digit ZIP Code) (Middle Initial) (Middle Initial) (Middle Initial) (Print) Print (Spouse/CU Partner's Middle Initial) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) 0 (text) 0 *131441100* *131441200* *141221100* *141221200* 1 Claimant 2 Spouse/CU Partner 3 Other Persons 10000 00 2014 may still qualify for a property tax adjustment A $15 late filing fee will be deducted from the adjustment 5454Signature Date Telephone Number a property tax adjustment This schedule must be filed with the HS 122 a VT homestead on April 1 even if a claim for property tax adjustment is not made A1 VT School Code A2 City/Town of Legal Residence on 04/01/2014 State A3 SPAN Number REQUIRED (From the 2013/2014 property tax bill) A4 Business Use of Dwelling A4 A6 Business or Rental Use of Improvements or Other Buildings A7 A10 Special Situations (see instructions for more information) Check the following if it applies: A7 Grantor and sole beneficiary of a A8 Life estate holder of the property A9 Homestead property crosses town boundaries Add all three amounts from Line s If a negative amount enter zero (0) t Add all three amounts from Line u v Add Lines a through m n Add Lines o p and total of Lines q1 to q5 foreach column r ADJUSTMENTS TO INCOME Alimony support money child support ALL eligibility questions must be answered You must own and occupy the property as your primary home on April 1 2014 Amounts for Lines B4 B6 are found on the 2013/2014 property tax bill Round amounts to the nearest dollar and belief they are true correct and complete Preparers cannot use return information for purposes other than preparing returns and include with the filing AND Property TaxAdjustment Claim ANNUAL Vermont Homestead Declaration ATTACH REQUIRED SCHEDULE HI 144 Attach W 2 and/or Federal Schedule SE if notincluded with income tax filing o 00 B1 Were you domiciled in VT all of calendar year 2013? cYes Go to Line B2 B10 Allocated Education Tax B10 B11 Allocated Municipal Tax B11 B12 Contiguous property Education Tax B12 B13 Contiguous property Municipal Tax B13 B2 Were you claimed as a dependent in 2013 by another taxpayer? cYes STOP B3 Do you anticipate selling your VT housesite on or before April 1 2014? cYes STOP B4 Housesite Value B4 B5 Housesite Education Tax B5 B6 Housesite Municipal Tax B6 B7 Ownership Interest B7 B8 Household Income (Schedule HI 144 Line y) Schedule HI 144 MUST be attached B8 B8a If AMENDED SCHEDULE HI 144 Household Income is attached check here B9 Mobile Home Lot Rent (Form LC 142 Line 16 attach Form to this claim) B9 be filed with the Renter Rebate Claim Claims are due April 15 2014 but can be filed up to October 15 2014 bottom of page 2 Business Expenses for Reservists(1040 Line 24) q1 Business income If the amount is a loss cA10 Residing in a dwelling owned by a related Capital gains taxable and nontaxable cash gifts g Cash public assistance and relief a cFORM HS 122 OR cFORM PR 141 Check here if authorizing the VT Department of Taxes to discuss this return and attachments with your preparer CHECK IF AMENDING Claimant s Date of Birth (MM DD YYYY) Claimant s Date of Birth / / Claimant s Last Name Claimant s Social Security Number cNo CONTINUE cNo Go to Line B3 cNo STOP Complete if born 1/1/1949 and after Complete the following ONLY if applicable See instructions on page 41 for details Continue on to complete Section B or continued on back Schedule HI 144 DUE DATE: April 15 2014 Enter interest and dividend income from enter zero See instructions for entry may differ from W 2/1099 or Federal ScheduleSE amount if these taxes are paid on income notrequired to be reported on Schedule HI 144 Estate or Trust income If the amount is a Farm/partnerships/S corporations/LLC/ farmer Firm s name (or yours if self employed) and address EIN First Name First Name First Name First Name For Household Income up to approx $105 000 Attach Schedule HI 144 for only exception to offset a loss l For the year Jan 1 Dec 31 2013 Form HS 122 Form HS 122 Due Date April 15 2014 Homeowners filing a completed HS 122 and HI 144 between April 16 and October 15 Form HS 122 page 2 of 2 Form HS 122 Property Tax Adjustment Claim must be filed each year Form HS 122 Section B and Schedule HI 144 are required to file a Property Tax Adjustment Claim Health Savings account deduction(1040 Line 25) q5 HI 144 Homeowners with Household Income up to $105 000 on Line y should complete Form HS 122 Section B You may be eligible for HOMEOWNERS: Homestead Declaration Household Income2013 HS 122 If a negative amount enter zero (0) s If Household Income is more than $47 000 you do not qualify for a renter rebate 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 If the amount is a loss enter zero If you will not be filing a Property Tax Adjustment Claim please sign in the signature section at the IMPORTANT FILING INFORMATION INCOME 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 Income Schedule You will not receive a Property Tax Adjustment unless you file a Homestead Declaration a Property Initial Initial Initial Initial Interest and dividends e Interest on U S state and municipal is a loss enter zero See instructions for j Taxable pensions annuities IRA and otherretirement fund distributions Lines e and f u 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 2013 Include their Location of Homestead (number street/road name (Do not use PO Box same or Town name) loss enter zero See Line i instructions Lot Rent Mail to: Mailing Address (Number and Street/Road or PO Box) MAXIMUM ADJUSTMENT AMOUNT IS $8 000 Montpelier VT 05601 1881 Not including the dwelling are improvements or other buildings located on your parcel o See instructions Enter Social Security and Medicare1 Amount from Line n Column 1 2 Amount from Line n Column 2 3 Amount from Line n Column 3 obligations taxable and nontaxable f offsetting a loss h offsetting a loss k OR Allocated Property Tax from Land Trust Cooperative or Nonprofit Mobile Home Park OR Property Tax from contiguous property if housesite has less than 2 acres (see instructions) Other income (See instructions for examplesof other income) Other Person #1 Last Name Other Person #1 Social Security Number Other Person #2 Last Name Other Person #2 Social Security Number p Child support paid You must attach proofof payment See instructions p 00 Please complete Section A and Section B sign and send to the Department together with a completed HI 144 Household Please complete Section A sign in the signature section at the bottom of page 2 and send to the Department Please PRINT in BLUE or BLACK INK Please PRINT in BLUE or BLACK INK This form can be filed on line at www tax vermont gov Please specify m PO Box 1881 Preparer s Preparer s signature Date Preparer s Preparer s Telephone Number PROPERTY TAX ADJUSTMENT CLAIM q Allowable Adjustments from Federal Form 1040 or 1040A q2 Alimony paid (1040 Line 31a) q2 Rental and royalty income If the amount RENTERS: revocable trust owning the property (File a declaration for each town ) SCHEDULE Schedule HI 144 Schedule HI 144 page 2 of 2 SECTION A This form must be filed EACH YEAR by ALL VT residents who own and occupy SECTION B See instructions for offsetting a loss i See instructions j Self employed health insurancededuction (1040 Line 29) q4 Signature If a joint return BOTH must sign Date Social Security Number Social security/railroad retirement/veteran sbenefits taxable and nontaxable b Spouse or CU Partner Last Name Spouse or CU Partner Social Security Number SSN or State Subtract Line r from Line n of each column Subtract Line w from Line v If Line w is more than Line v enter zero (0) x Support paid to: Last Name Tax Adjustment Claim and a Household Income schedule tax from Federal Schedule SE This tax withheld on wages Self Employed: Enter selfemployment This schedule must be attached to the 2013 Renter Rebate Claim (Form PR 141) OR the 2014 Property Tax Adjustment Claim (Form HS 122) To file a Homestead Declaration: To file a Property Tax Adjustment Claim: TOTAL INCOME: Tuition and Fees (1040 Line 34 or1040A Line 19) q3 Under penalties of perjury I declare that I have examined this return and accompanying schedules and statements and to the best of my knowledge Unemployment compensation/worker scompensation c UNLESS you are filing an AMENDED HI 144 Please read instructions before completing schedule Use Only used for business or rented? cYes cNo VERMONT VERMONT *141221100* VT Department of Taxes Wages salaries tips etc (See instructionsfor dependent s exempt income ) d Will you be filing a Property Tax Adjustment claim at a later date? cYes cNo y HOUSEHOLD INCOME Add Line t and Line x y Yearly totals of ALLmembers of the household ZIP Code