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4 Vermont Department of Taxes Please PRINT 4
5 in BLUE or DEPT 5
6 Form IN-116 BLACK INK USE *231161100* 6
7 ONLY 7
8 Vermont Income Tax Payment Voucher *231161100* 8
9 Taxpayer’s Last Name First Name MI Taxpayer’s Social Security Number 9
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1234567890123(17) 1234567890123(17) 1 123456789
11 Spouse’s/CU Partner’s Last Name First Name MI Spouse’s or CU Partner’s Social Security Number 11
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1234567890123(17) 1234567890123(17) 1 123456789
13 Mailing Address (Number and Street/Road or PO Box) Tax Year 13
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12345678901234567890123456789012(36) 2023
15 City State ZIP Code or Postal Code 15
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123456748901234567(21) 12 1234567890 Amount of
17 123456789 Foreign Country (if not United States) this payment . . . . . . __________________________.00 17
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12345678901234567890123456789012(36)
19 Form IN-116 19
20 5454 If you electronically filed, DO NOT include a copy of the filed return with this payment . Rev.10/23 20
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26 Mail voucher and check made payable to “Vermont Department of Taxes” to: 26
27 Vermont Department of Taxes 27
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PO Box 1779
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30 Montpelier, VT 05601-1779 30
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