Fillable Page 27 2021 Form HS-122 Vermont Homestead Declaration (Vermont)

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Page 27 2021 Form HS-122 Vermont Homestead Declaration (Vermont)

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Page 27
Claimant’s Last Name First Name MI Claimant’s Social Security Number
Spouse’s/CU Partner’s Last Name First Name MI Spouse’s or CU Partner’s Social Security Number
Mailing Address (Number and Street/Road or PO Box) Claimant’s Date of Birth (MMDDYYYY)
City State ZIP Code SPAN - REQUIRED (from the 2020/2021 property tax bill)
Location of Homestead (Use a number, street/road name. Do not use a PO Box or “same.”) City/Town of Legal Residence on April 1, 2021 & State
Head of
Household
Married/CU
Filing Separately
Married/CU
Filing Jointly
Single
Federal
Filing Status
A1. Business Use of Dwelling ............................................................... . . . . . . A1. __________________ %
A2. Rental Use of Dwelling ................................................................. . . . . . . A2. __________________ %
A3. Business or Rental Use of Improvements or Other Buildings
Not including the dwelling, are improvements or other buildings located on your parcel used for business or rented? ....A3.
A4-A7 Special Situations (see instructions for more information). Check the following if it applies:
DUE DATE: April 15, 2021. You may file up to Oct. 15, 2021, but the town may assess a penalty. For details on late filing, see the instructions.
How to file a Homestead Declaration: Please complete Section A of this form, sign in the signature section at the bottom of page 2, and send
the form to the Vermont Department of Taxes
How to file a Property Tax Credit Claim: To be considered for a Property Tax Credit, you must file a 1) Homestead Declaration (Section A of
this form), 2) Property Tax Credit Claim (Section B of this form), and 3) Schedule HI-144, Household Income. Sign this form
in the signature section at the bottom of page 2 and send the forms to the Department.
Tired of paper forms? It’s fast and convenient to file your claim online at myVTax.vermont.gov.
Please PRINT in BLUE or BLACK INK
Form HS-122
Rev. 10/20Page 1 of 2
Annual Vermont Homestead Declaration
This form must be filed each year by every Vermont resident whose property meets the definition of a homestead.
A Vermont homestead is the principal dwelling and parcel of land surrounding the dwelling, owned and occupied by a resident
individual as the individual’s domicile on April 1, 2021. If your homestead is leased to a tenant on April 1, 2021, you may still
claim it as a homestead if it is not leased for more than 182 days in the 2021 calendar year.
SECTION A.
Yes No
Vermont Department of Taxes
2021 Form HS-122
Vermont Homestead Declaration AND
Property Tax Credit Claim
Residing in a dwelling on the homestead
parcel owned by a related farmer.
A7.
Homestead property crosses town boundaries
(File a declaration for each town.)
A6.
Grantor and sole beneficiary of a
revocable trust owning the property
A4.
Life estate holder of the property
A5.
Please continue to Page 2, Part B, for property tax credit. Sign on Page 2.
Mail to: Vermont Department of Taxes
PO Box 1881
Montpelier, VT 05601-1881
/ /
*211221100*
*211221100*
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Page 28
DUE DATE: April 15, 2021. Claims accepted up to Oct. 15, 2021.
PROPERTY TAX CREDIT CLAIM
For Household Income up to $138,500. Complete and attach Schedule HI-144.
SECTION B.
To qualify, you must meet the requirements for filing a homestead declaration in addition to the following requirements.
ALL eligibility questions must be answered.
Form HS-122
Rev. 10/20
Page 2 of 2
Claimant’s Last Name Social Security Number
Yes, Go to Line B2. No, STOP.
Yes, STOP.
No, Go to Line B3.
Yes, STOP. No, Continue
Check here if amended Schedule
HI-144, Household Income, is included.
MAXIMUM CREDIT AMOUNT IS $8,000.
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 (MMDDYYYY) Daytime Telephone Number
Signature (If a joint return, BOTH must sign.) Date (MMDDYYYY) Daytime Telephone Number
Paid Preparer’s Signature Date (MMDDYYYY) Preparer’s Telephone Number
Firm’s Name (or yours if self-employed) and address Preparer’s SSN or PTIN FEIN
-
*211221200*
*211221200*
B1. Were you domiciled in Vermont all of calendar year 2020? .......
B2. Were you claimed as a dependent in 2020 by another taxpayer? ....
B3. Do you anticipate selling this Vermont housesite on or
before April 1, 2021? ............................. . . . . . . . .
Amounts for Lines B4-B6 are found on the 2020/2021 property tax bill. Round amounts to the nearest dollar.
B4. Housesite Value .......................................................................B4. __________________________.00
B5. Housesite Education Tax .................................................................B5. __________________________.00
B6. Housesite Municipal Tax ................................................................B6. __________________________.00
B7. Ownership Interest .................................................................... . . . . . . .B7. __________________ %
B8. Household Income (Schedule HI-144, Line z).
You MUST attach Schedule HI-144
............................ B8. _____________________ .00
Complete the following ONLY if applicable. See instructions for details.
B9. E-file Certificate Number (from Form LC-142) ........................B9. _______________________________________________________
B10. Lot Rent (Allocable Rent from Form LC-142 - include Form LC-142 with claim.) ..................B10. __________________________.00
Attach documentation for Allocated Property Tax from Land Trust, Cooperative, or Nonprofit Mobile Home Park
B11. Allocated Education Tax ................................................................B11. __________________________.00
B12. Allocated Municipal Tax ................................................................B12. __________________________.00
OR Property Tax from contiguous property if housesite has less than 2 acres
(see instructions.)
B13. Contiguous property Education Tax .......................................................B13. __________________________.00
B14. Contiguous property Municipal Tax .......................................................B14. __________________________.00
Check if the Department of Taxes may discuss this return with the preparer shown.
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Page 29
Please PRINT in BLUE or BLACK INK
This schedule must be included with the 2020 Renter Rebate Claim (Form PR-141) OR the 2021 Property Tax Credit Claim (Form HS-122).
Please read instructions before completing schedule.
List the names and Social Security Numbers of all other persons (in addition to a Spouse or CU Partner) who had income and lived with you during
2020. Include both 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.
Yearly totals of ALL
members of the household
1. Claimant /Claimant
and jointly filed Spouse
2. Filing separately
Spouse or CU Partner
3. Other Persons
Schedule HI-144
Rev. 10/20
a. Cash public assistance and relief (See instructions for exclusions) ... a. ____________.00 ____________.00 ___________ .00
b. Social Security, SSI, disability, railroad retirement,
veteran’s benefits, taxable and nontaxable . . . . . . . . . . . . . . . . . . . . . . b. ____________.00 ____________.00 ___________ .00
c. Unemployment compensation/worker’s compensation ............. c. ____________.00 ____________.00 ___________ .00
d. Wages, salaries, tips, etc. (See instructions for
dependent’s exempt income.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. ____________.00 ____________.00 ___________ .00
e. Interest and dividends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e. ____________.00 ____________.00 ___________ .00
f. Interest on U.S., state, and municipal obligations,
taxable and nontaxable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .f. ____________.00 ____________.00 ___________ .00
g. Alimony and support money . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . g. ____________.00 ____________.00 ___________ .00
h. Child support and cash gifts
Please specify__________________________ ..................h. ____________.00 ____________.00 ___________ .00
i. Business income. If the amount is a loss, enter -0-.
See instructions for offsetting a loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . i. ____________.00 ____________.00 ___________ .00
j. Capital gains, taxable and nontaxable. If the amount is a loss,
enter -0-. See instructions for offsetting a loss ...................j. ____________.00 ____________.00 ___________ .00
k. Taxable pensions, annuities, IRA and other retirement fund and
distributions. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . k. ____________.00 ____________.00 ___________ .00
l. Rental and royalty income. If the amount is a loss, enter -0-.
See instructions for offsetting a loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . l. ____________.00 ____________.00 ___________ .00
m. Farm/partnerships/S corporations/LLC/Estate or Trust income.
If the amount is a loss, enter -0-. See Line m instructions for only
exception to offset a loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .m. ____________.00 ____________.00 ___________ .00
n. Other income (see instructions for examples of other income)
Please specify__________________________ ..................n. ____________.00 ____________.00 ___________ .00
o. Total Income: Add Lines a through n . . . . . . . . . . . . . . . . . . . . . . . . o. _____________.00 _____________ .00 _____________.00
Page 1 of 2
Claimant’s Last Name First Name MI Claimant’s Social Security Number
Spouse’s/CU Partner’s Last Name First Name MI Claimant’s Date of Birth (MMDDYYYY)
Vermont Department of Taxes
2020 Schedule HI-144
Household Income
For the year Jan 1 - Dec 31, 2020
Other Person #1 Last Name First Name MI Other Person #1 Social Security Number
Other Person #2 Last Name First Name MI Other Person #2 Social Security Number
FORM (Place at FIRST page)
Form pages
29 - 30
*201442100*
*201442100*
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Page 30
p. See instructions. Enter Social Security and
Medicare tax withheld on wages claimed on
Line d. Self-Employed: Enter self-employment
tax from Federal Schedule SE. This entry may
differ from W-2/1099 or Federal Schedule SE
amount if these taxes are paid on income not
required to be reported on Schedule HI-144.
Include W-2 and/or Federal Schedule SE
if not included with income tax filing ..... p.____________ .00 ____________ .00 ____________.00
q. Child support paid. You must include
proof of payment. See instructions ....... q._____________ .00 _____________ .00 _____________ .00
r. Allowable adjustments from Federal Form 1040
r1. Business expenses for Reservists ....r1. ___________ .00 ____________ .00 ____________.00
r2. Alimony paid ...................r2. ___________ .00 ____________ .00 ____________.00
r3. Self-employed health
insurance deduction ...............r3. ___________ .00 ____________ .00 ____________.00
r4. Health Savings Account deduction ...r4. ___________ .00 ____________ .00 ____________.00
r5. Tuition and Fees as reported on
federal Form 8917 ................r5. ___________ .00 ____________ .00 ____________.00
s. Add Lines p, q, and total of Lines r1 to r5
for each column .......................s. ___________ .00 ____________ .00 ____________.00
t. Subtract Line s from Line o of each column.
If a negative amount, enter -0- . ...........t. ___________ .00 ____________ .00 ____________.00
u. Add all three amounts from Line t. If a negative amount, enter -0- .............................................u. ___________ .00
v. Complete if born Jan. 1, 1956 and after.
Enter interest and dividend income from
Lines e and f. .........................v. ___________ .00 ____________ .00 ____________.00
w. Add all three amounts from Line v ..................................................................... w. ___________ .00
x. Asset Adjustment of Interest and Dividend Income (Lines e and f). Per 32 V.S.A. § 6061E .........................x. _______________
y. Subtract Line x from Line w. If Line x is more than Line w, enter -0- . .........................................y. ___________ .00
z. HOUSEHOLD INCOME. Add Line u and Line y .........................................................z. ___________ .00
RENTERS If Line z Household Income is $47,000 or less, you may be eligible for a renter rebate. Complete Form PR-141 Renter Rebate Claim.
This schedule must be filed with the Renter Rebate Claim. Claims are due April 15, 2021, but can be filed up to Oct. 15, 2021.
If Household Income is more than $47,000, you do not qualify for a renter rebate.
HOMEOWNERS Form HS-122, Homestead Declaration AND Property Tax Credit Claim, must be filed each year.
Homeowners with Household Income up to $138,500 on Line z should complete Form HS-122, Section B. You may be eligible for
a property tax credit. This schedule must be filed with Form HS-122.
Form HS-122 The due date to file is April 15, 2021. Homeowners filing a property tax credit, Form HS-122 and Schedule HI-144,
between April 16 and Oct. 15, 2021, may still qualify for a Property Tax Credit. A $15 late filing fee will be deducted from
the credit.
Schedule HI-144
Rev. 10/20Page 2 of 2
Claimant’s Last Name Social Security Number
Support paid to: Last Name First Name MI Social Security Number
10,000.00
1. Claimant /Claimant
and jointly filed Spouse
2. Filing separately
Spouse or CU Partner
3. Other Persons
Carried forward from Line o ......_____________ .00 _____________ .00 _____________ .00
FORM (Place at LAST page)
Form pages
29 - 30
*201442200*
*201442200*
5454
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