Vermont Department of Taxes                                 Please PRINT 
                                                                  in BLUE or             DEPT 
      Form IN-116                                                 BLACK INK              USE       *231161100*
                                                                                         ONLY
Vermont Income Tax Payment Voucher                                                                 *231161100*
      Taxpayer’s Last Name                                First Name                     MI             Taxpayer’s Social Security Number
  1234567890123(17)       1234567890123(17)    1   123456789
  Spouse’s/CU Partner’s Last Name                         First Name                     MI        Spouse’s or CU Partner’s Social Security Number
  1234567890123(17)       1234567890123(17)    1   123456789
           Mailing Address (Number and Street/Road or PO Box)                                                             Tax Year
  12345678901234567890123456789012(36)               2023            
      City                                         State          ZIP Code or Postal Code
  123456748901234567(21)   12   1234567890                                                    Amount of 
                                                              123456789 Foreign Country (if not United States) this payment   . . . . .  . __________________________.00
  12345678901234567890123456789012(36)
                                                                                                                                         Form IN-116
5454  If you electronically filed, DO NOT include a copy of the filed return with this payment .                                         Rev.10/23

     Mail voucher and check made payable to “Vermont Department of Taxes” to: 
      Vermont Department of Taxes
      PO Box 1779
      Montpelier, VT  05601-1779