Vermont Department of Taxes 

               2024 Form HS-122                                                                     *241221100*
 Vermont Homestead Declaration AND                                                                  *241221100*
          Property Tax Credit Claim                                                                                                                                                                          Page 29

DUE DATE:      April 15, 2024 .  You may file up to Oct . 15, 2024, but the town may assess a penalty .  For details on late filing, see 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 .
                                                                                                                                                                                                             FORM  (Place at FIRST page)
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                                                                  Form pages
               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.

                                                   Annual Vermont Homestead Declaration
                                                                                                                                                                                                             29 - 30
               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 
 SECTION A.    individual as the individual’s domicile on April 1, 2024 .  If your homestead is leased to a tenant on April 1, 2024, you may still 
               claim it as a homestead if it is not leased for more than 182 days in the 2024 calendar year .
Please PRINT in BLUE or BLACK INK
               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 (MM/DD/YYYY)
                                                                                                                       /        /
               City                                State                      ZIP Code 

          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, 2024  and  State

 Federal  
 Filing Status Single                                    Married/CU                                         Married/CU                                                                  Head of 
                                                         Filing Jointly                                     Filing Separately                                                           Household

  A1. SPAN - REQUIRED (from the 2023/2024 property tax bill)  . . . . . . . . . . . . . . . . . . . . . . . .A1.  ______________________________________-                              -

 A2.  Business Use of Dwelling  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  .  .  .  .  .  .  .   A2.  __________ .______ %

  A3. Rental Use of Dwelling  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  .  .  .  .  .  .  . A3.  __________ .______ %

 A4.  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?  . . .  .A4.                                                  Yes                No

A5-A8 Special  Situations (See instructions for more information) . Check the following if it applies:

          A5.  Grantor and sole beneficiary of a                                A7.    Homestead property crosses town boundaries
               revocable trust owning the property                                     (File a declaration for each town.)
          A6.  Life estate holder of the property                               A8.    Residing in a dwelling on the homestead
                                                                                       parcel owned by a related farmer.

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                                                                                          2024 Form HS-122
                                                                                                                                                                                       Page 1 of 2
               5454                                                                                                                                                                    Rev. 10/23

                           Claimant’s Last Name      Social Security Number

                                                                                                                             *241221200*
DUE DATE:   April 15, 2024. Generally, claims cannot be accepted after Oct. 15, 2024.                                        *241221200*
                                                                                                                                                                                                                    Page 30
                                                     PROPERTY TAX CREDIT CLAIM
 SECTION B.
                           For Household Income up to $128,000.  Complete and attach Schedule HI-144.
To qualify, you must meet the requirements for filing a homestead declaration in addition to the following requirements.
ALL eligibility questions must be answered.
 B1.  Were you domiciled in Vermont all of calendar year 2023?   . . . . . . .                                    Yes, Go to Line B2.                                  No, STOP.
                                                                                                                                                                                                                    FORM  (Place at LAST page)
 B2.   Were you claimed as a dependent in 2023 by another taxpayer?  . . . .                                      Yes, STOP.                                           No, Go to Line B3.                           Form pages 
 B3.   Do you anticipate selling this Vermont housesite on or  
       before April 1, 2024?   . . . . . . . . . . . . . . . . . . . . . . . . . . . .  .  .  .  .  .  .  .  .  . Yes, STOP.                                           No, Continue
Amounts for Lines B4 through B6 are found on the 2023/2024 property tax bill.  Round amounts to the nearest dollar.

  B4.  Housesite Value   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  .B4. __________________________.00            29 - 30

B5.    Housesite Education Tax  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  .B5. __________________________.00

  B6.  Housesite Municipal Tax   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  .B6. __________________________.00

  B7.  Ownership Interest   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  .  .  .  .  .  .  .  .B7.  __________ .______ %
  B8.  Household Income (Schedule HI-144, Line z) .                                                                                                                    Check here if amended Schedule 
       You MUST attach Schedule HI-144  . . . . . . . . . . . . . . . . . . . . . . . . . . . .                   B8.  _____________________ .00                       HI-144, Household Income, is included.

Complete the following ONLY if applicable from Form LRC-147, Part B .

  B9.  For Profit Mobile Home Lot Rent (Allocable Rent from Form LRC-147)   . . . . . . . . . . . . . . . . . . . . . . . . .  .B9. __________________________.00

Not-For-Profit Mobile Home Park, Cooperative, and Land Trust

  B10. Allocated Education Tax  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  .B10. __________________________.00

 B11.  Allocated Municipal Tax  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  .B11. __________________________.00

 OR Property Tax from contiguous property if housesite has less than 2 acres                                       (See instructions.)

  B12. Contiguous property Education Tax  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  .B12. __________________________.00

  B13. Contiguous property Municipal Tax  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  .B13. __________________________.00
                                                     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

                                                                                                                                                                       2024 Form HS-122
                           Check if the Department of Taxes may discuss this return with the preparer shown.                                                                                 Page 2 of 2
            5454                                                                                                                                                                             Rev. 10/23

       Clear ALL fields                              Save and go to Important Printing Instructions                                                                                          Save and Print

             Vermont Department of Taxes 

             2023 Schedule HI-144                                                                                                                          *231441100*
                  Household Income                                          Please PRINT in BLUE or BLACK INK                                              *231441100*
               For the year Jan. 1 - Dec. 31, 2023                                                                                                                                                                Page 31
This schedule must be included with the 2024 Property Tax Credit Claim (Form HS-122) .  Please read instructions before completing schedule .
                  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)

List the names and Social Security Numbers of all other people (in addition to a Spouse or CU Partner) who had income and lived with you during 
2023 . Include both their taxable and non-taxable income in Column 3 . If you have more than two “Other People” living in your household, record the 
names and Social Security Numbers on a separate sheet of paper and include with the filing .
     Check this box if you temporarily hosted a refugee, asylee, or asylum seeker in your home during 2023 .  Do not include their income on this form .

               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 
               Yearly totals of ALL                                                                                                        1. Claimant /Claimant    2. Filing separately            Other People
           members of the household                                                                 and jointly filed Spouse                                        Spouse or CU Partner         3. 

 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 31 - 32

 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
                                                                                                                                                                                2023 Schedule HI-144
                                                                                                                                                                                                 Page 1 of 2
                  5454                                                                                                                                                                           Rev. 10/23

                             Claimant’s Last Name                          Social Security Number

                                                                                                                                   *231441200*
                                                                                                                                   *231441200*
                                                                                                                                                                                                           Page 32
              Carried forward from Line o                    . . . . . . _____________ .00                _____________ .00                         _____________ .00

 p. See instructions . Enter Social Security and                     1. Claimant /Claimant                 2. Filing separately                          Other People
    Medicare tax withheld on wages claimed on                        and jointly filed Spouse          Spouse or CU Partner                          3. 
    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

            Support paid to:  Last Name                                                    First Name                                  MI                                Social Security Number

                                                                                                                                                                                                           FORM  (Place at LAST page)
 r. Allowable adjustments from federal Form 1040                                                                                                                                                           Form pages 
     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                                        31 - 32

    r4.  Health Savings Account deduction  . .  .                r4.  ___________ .00                     ____________           .00                ____________.00
 s. ADD Lines p, q, and total of   
    Lines r1 through r4 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, 1959 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.  _______________10,000.00

 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

HOMEOWNERS           Form HS-122, Homestead Declaration AND Property Tax Credit Claim, must be filed each year .
                     Homeowners with Household Income up to $128,000 on Line z should complete Form HS-122, Section B . You may be eligible for 
                             a property tax credit . Schedule HI-144 must be filed with Form HS-122 .
                     The due date to file Form HS-122 is April 15, 2024 . Homeowners filing a property tax credit, Form HS-122, Section B, and 
                             Schedule HI-144, between April 16 and Oct . 15, 2024, may still qualify for a Property Tax Credit .  A $15 late filing fee will be 
                             deducted from the credit . Generally, claims cannot be accepted after Oct . 15, 2024 .

                                                                                                                                                                       2023 Schedule HI-144
                                                                                                                                                                                         Page 2 of 2
                5454                                                                                                                                                                     Rev. 10/23