Vermont Department of Taxes                 Telephone:  (802) 828-2865
Taxpayer Services Division                              (866) 828-2865
PO Box 1645                                 Fax:        (802) 828-2720
Montpelier, VT  05601-1645                  Email:      tax.individualincome@vermont.gov

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 Vermont Homestead Declaration and/or Property Tax Credit                                            FORM                                                           1

                                    WITHDRAWAL                                          HS-122W

            Declarant’s Last Name                                     First Name                  MI Declarant’s Social Security Number    

            Spouse’s/CU Partner’s Last Name                           First Name                  MI Spouse’s or CU Partner’s Social Security Number

            Current Mailing Address                                   City                           State                      ZIP Code

PROPERTY BEING WITHDRAWN
 SPAN (School Property Account Number on tax bill) PHYSICAL LOCATION of property (number and street, road, or route name)       Date that Form HS-122 was filed

 PROPERTY SALES AND CHANGES AFTER FILING A 2024 VERMONT HOMESTEAD DECLARATION

                                             AND/OR PROPERTY TAX CREDIT CLAIM                                                                                  FORM  (Place at FIRST page)
                                                                                                                                                               Form pages 
A 2024 Vermont Homestead Declaration and Property Tax Credit claim requires the property owner as of 
April 1, 2024, to occupy the property as their domicile.  If your homestead is leased to a tenant on April 1, 2024, 
it may still be declared a homestead if it is not leased for more than 182 days in the 2024 calendar year.  Use this 
form to withdraw a Vermont Homestead Declaration and/or Property Tax Credit claim if one of the following 
events occur:                                                                                                                                                  1 - 1

  Property sold on or before April 1, 2024.  Name of Buyer  ______________________________________

                                                        Date sold ____________________

  Property was rented on April 1, 2024, and leased for more than 182 days in 2024.

  Property converted to nonhomestead before April 1, 2024.

  Vermont Homestead Declaration submitted in error.  The property was not my principal residence on 
 April 1, 2024.

  Claimant of the Property Tax Credit died before April 1, 2024.
            Estates may claim homestead for purpose of homestead property tax provided the property is not rented.

  Other.  Please explain. __________________________________________________________________

  ____________________________________________________________________________________  

            I am hereby withdrawing my Homestead Declaration and/or Property Tax Credit as described above.

                                                                                                                                                               FORM  (Place at LAST page)
                                                                                                                                                               Form pages 
 Declarant’s Signature                                                Date                           Telephone Number

            Check here if authorizing the Vermont Department of Taxes to discuss this return and attachments with your preparer.
 Paid preparer’s use only.
                                                                                                                                                               1 - 1
 Preparer’s Signature                              Date               Preparer’s Telephone Number    Preparer’s EIN/SSN/PTIN
                                                                                                                                Form HS-122W
                                                                                                                                Page 1 of 1
                                                                                                                                Rev. 10/23