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       E-mail:                      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                                             Declarant’s First Name and Initial                                     Declarant’s SSN
                                                                                                                                                         _         _
 Spouse’s/CU Partner’s Last Name                                   Spouse’s/CU Partner’s First Name and Initial                           Spouse’s/CU Partner’s SSN
                                                                                                                                                         _         _
 Current Mailing Address                                           City or Town                                                           State          Zip Code

 PROPERTY   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
 BEING 
 WITHDRAWN

 PROPERTY SALES AND CHANGES AFTER FILING A 2021 VERMONT HOMESTEAD DECLARATION

                                                              AND/OR PROPERTY TAX CREDIT CLAIM
                                                                                                                                                                                        FORM  (Place at FIRST page)
A 2021 Vermont Homestead Declaration and Property Tax Credit claim requires the property owner as of                                                                                    Form pages 
April 1, 2021, to occupy the property as his/her domicile.  If your homestead is leased to a tenant on April 1, 2021, 
it may still be declared a homestead if it is not leased for more than 182 days in the 2021 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, 2021.  Name of Buyer  _______________________

                                                                   Date sold ____________________________

  Property was rented on April 1, 2021, and leased for more than 182 days in 2021.

  Property converted to nonhomestead before April 1, 2021.

  Vermont Homestead Declaration submitted in error.  The property was not my principal residence on 
       April 1, 2021.

  Claimant of the Property Tax Credit died before April 1, 2021.
            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
                                                                                                                                                           Rev. 10/20