Montpelier VT 05601 1779
PO Box 1779
(Rev 11/15)
*151161100*
Address Tax Year (YYYY)
Amount of this payment $
City State ZIP Code
For Department Use Only
Foreign Country (if not United States)
Form IN 116
If you electronically filed DO NOT include a copy of the filed return with this payment
IN 116
INCOME TAX PAYMENT VOUCHER
Last Name First Name Initial Taxpayer s Social Security Number
Mail to: Vermont Department of Taxes
Make check payable to: VERMONT DEPARTMENT OF TAXES
payment with Form IN 111
Spouse s or CU Partner s Last Name First Name Initial Spouse s or CU Partner s Social Security Number
Use this form if NOT submitting
VT Form
