STATE OF VERMONT DEPARTMENT OF TAXESwebservicesfp.lscsoft.com/downloads/forminstructions/2012/Vermo… · * Schedule HI-144 must be submitted with each subset (subsets 3 and 4)

DRAFT 21 NOV 2012

STATE OF VERMONTDEPARTMENT OF TAXES

Scanband Specifications

INCOME

2012 TAX YEAR

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DRAFT 21 NOV 2012

New this year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Issues from last year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3List of Individual Income forms being scanned this year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Letter of Intent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Test Cases and Sample Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4General Specifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5SAMPLE FORMS and SCHEDULES - Full-field & “page 2” (taxpayer-readable)

IN-111, Income Tax Return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-9IN-112, Tax Adjustments and Credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-11IN-113, Income Adjustment Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-13IN-114, Individual Income Estimated Tax Payment Voucher . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14IN-116, Income Tax Payment Voucher . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15IN-117, Credit for Income Tax Paid to Other State or Canadian Province . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16IN-119, Tax Credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17-18HS-122, Homestead Declaration AND Property Tax Adjustment Claim (replaces HS-131 & HS-145) . . . . . . . . . 19-20PR-141, Renter Rebate Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21HI-144, Household Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22-23IN-151, Extension of Time to File Form IN-111 Individual Income Tax Return . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24IN-152 (vendor version), Underpayment of 2012 Estimated Individual Income Tax . . . . . . . . . . . . . . . . . . . . . . . . . .25IN-152A (vendor version), Annualized Income Installment Method for Underpayment of 2012 Estimated Individual Income Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26IN-152 (Dept . version), Underpayment of 2012 Estimated Individual Income Tax . . . . . . . . . . . . . . . . . . . . . . . . . . .27IN-152A (Dept . version), Annualized Income Installment Method for Underpayment of 2012 Estimated Individual Income Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28IN-153, Capital Gain Exclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29-30IN-154, State/Local Income Tax Addback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31RW-171, Vermont Withholding Tax Return for Transfer of Real Property . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32-33

SPECIFICATIONS - Field identifiers (boxes) & written specificationsIN-111, Income Tax Return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34-39IN-112, Tax Adjustments and Credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40-44IN-113, Income Adjustment Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45-51IN-114, Individual Income Estimated Tax Payment Voucher . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52-54IN-116, Income Tax Payment Voucher . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55-57IN-117, Credit for Income Tax Paid to Other State or Canadian Province . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58-60IN-119, Tax Credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61-66HS-122, Homestead Declaration AND Property Tax Adjustment Claim (replaces HS-131 & HS-145) . . . . . . . . . 67-70PR-141, Renter Rebate Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71-73HI-144, Household Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74-80IN-151, Extension of Time to File Form IN-111 Individual Income Tax Return . . . . . . . . . . . . . . . . . . . . . . . . . . 81-82IN-152/IN-152A (all versions), Underpayment of 2012 Estimated Individual Income Tax . . . . . . . . . . . . . . . . . . . . .83IN-153, Capital Gain Exclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84-86IN-154, State/Local Income Tax Addback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87-88RW-171, Vermont Withholding Tax Return for Transfer of Real Property . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89-91

Table of Contents

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DRAFT 21 NOV 2012NEW THIS YEAR:

-- First submittals must be received no later than January 14, 2013.-- Form HS-122 - combines and replaces Forms HS-131 (Homestead Declaration) and PR-145 (Property Tax

Adjustment Claim) .-- A Homestead Declaration (Form HS-122, Section A) DOES need to be filed each year by every VT

homeowner .-- Form IN-151 has text changes but should be set up as a “generic year” form . See pages 81-82 for more

details .

Vermont will accept submittals (in subset groups only) based on DRAFTS . If your submitted forms meet our approval, we will give PRELIMINARY approval . When the forms are posted as FINAL, we will send a second e -mail to you . If there have been changes to the forms, we will notify you of those changes and request a resubmittal . If no changes are made, the second e-mail will be a FINAL approval . FORMS THAT ARE IN “PRELIMINARY APPROVAL” STATUS SHOULD NOT BE DISTRIBUTED FOR USE.

ISSUES FROM LAST YEARLast year there were several recurring issues or errors:

• “Mixed-form” returns were filed. A “mixed-form” return is one which uses a combination of two or more types of forms: (1) computer-generated, (2) Department-issued, and (3) forms downloaded from our website . Mixed-form returns were most often noticed in an IN-111/PR-141 combination . A vendor Form IN-111 was filed with Department-issued Form PR-141. Forms IN-111 and PR-141 may be filed separately. If they are filed separately, Form IN-111, Line 31d must be “0”. Form IN-111, Line 31d amount must come from Form PR-141, Line 9 . User should not be allowed to override the amount on Form IN-111, Line 31d .

• Punctuation was printed in the scanned fields on filed returns and incorrect font used. Test forms submitted for approval were correct and had no punctuation, used correct font, etc. but filed returns had punctuation and used incorrect font .

• Full-field forms should have only the allowed type of data for each field, that is, a dollar amount field should only show numbers and no alpha characters. Incorrect data type for full-field forms may cause delays in testing and approval process .

List of Individual Income forms being scanned for the 2012 tax year

IN-111 IN-112 IN-113 IN-114 IN-116 IN-117 IN-119 HS-122 PR-141 HI-144 IN-151 IN-152 IN-152A IN-153 IN-154 RW-171

NOTE: Form LC-142, Landlord’s Certificate, is not reproducible and should not be included in your software.

Forms will be approved in subsets as indicated on the following page . All forms in a subset must receive approval at the same time . Example: Form IN-111 will not receive approval until Schedules IN-112, IN-113, IN-116, IN-117, IN-119, IN-153, and IN-154 are approved . You are required to use the test samples found on our vendors-only website .

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DRAFT 21 NOV 2012Subsets allowed: 1) IN-111, IN-112, IN-113, IN-116, IN-117, IN-119, IN-153, IN-154 2) IN-114 3) HS-122, HI-144* 4) PR-141, HI-144* 5) IN-151 6) IN-152** 7) IN-152A** 8) RW-171

* Schedule HI-144 must be submitted with each subset (subsets 3 and 4) .

** Vendors may choose to recreate the Department-original version of IN-152 and IN-152A or the vendor version . If you create the vendor version, you will need to create (your own design) and submit worksheets for calculating interest and penalties . If you create the Department-original version, you do not need to create corresponding worksheets .

Forms must be approved as a unit because our scanner cannot process “mixed-form returns”; that is, some pages of computer-generated and some pages of Department-original forms . Each taxpayer’s return must be all computer-generated or all Department-original. The only exception to this is the Landlord’s Certificate (Form LC-142) which must be a Department-original form. The landlord is required to issue a Landlord’s Certificate to his/her tenants the same as an employer is required to issue a W-2 to his/her employees .

LETTER OF INTENTVendors must sign a “Letter of Intent” indicating the subsets of forms for which they intend to seek approval . A letter of intent can be found on our vendors-only website and also in our Substitute Forms Policy . Both are posted at www.state.vt.us/tax/vtvendors.shtml under “Paper Filing” . The letter of intent should be e-mailed to Penny Widmer at [email protected] prior to sending your first submittal of forms for approval or you must include the letter with your first package of forms for approval.

TEST CASES AND SAMPLE DATATest cases can be found on our vendors-only website at www.state.vt.us/tax/vtvendors.shtml . The test cases are designed to look for specific issues that we have experienced with each form. It is imperative that you use all the information provided in each test case, not just the name and address . If the sample(s) submitted do not use the test case information provided, the forms will be rejected.The forms provided in the test case package do not always include both pages of a form . If page 2 of the Department-original form is not included in a test case, then you may assume that there is no data required for that page and you should insert default values for those fields. Example: If page 2 of Schedule IN-112 (Parts III and IV) is not included in a test case, insert default data for those two calculations .

DUE DATEFirst submittals for substitute forms approval must be received by the Department no later than Monday, January 14, 2013 . First submittals received after January 14, 2013 will not be approved .

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DRAFT 21 NOV 2012GENERAL SPECIFICATIONS

FORM DESIGNMargins - There must be 1/2” left-hand margin on ALL pages printed. The front of each sheet of paper will receive a document locator number (DLN) printed onto the left-hand margin as it goes through our scanner . The forms in these specifications are designed with a 6/10” left margin to allow for a slight variance due to the use of different printers and ensure the 1/2” margin when printed .

Shading - should not be used on any part of the forms .

Barcode - The 6th digit in the barcode is “3” for the scanband forms . We are identifying scanband forms as “Version 3” . Page 2 (taxpayer-readable page) of the forms will not have a barcode . Worksheets IN-152 and IN-152A do not have a barcode .

Vendor ID Number - BARCODE - Each vendor that creates forms included in these specifications will put their 2-digit Vendor ID number which is assigned by the Vermont Department of Taxes in place of the “00” or “99” as the last two digits in the barcode . If you need a 2-digit ID number, please contact Penny Widmer at (802) 828-0684 or by e-mail at [email protected] .

“FOR COMPUTERIZED USE ONLY” is printed on each scanband .

Taxpayer-readable portion or “Page 2”:

• must be submitted for approval.

• must have a 1/2” left margin.• will not have a barcode.• must have the following text on the top of the page: “This page must be filed with Page 1 of

this form.” or “... this schedule.”, as applicable .• must have a decimal point at the end of the dollar amounts. Commas in the dollar amounts may

be used if you wish, but are not necessary .• must default empty numeric fields to zero (“0”).

PRINTED DATAUSE COURIER 12 POINT FONT FOR ALL SCANBAND DATA.

Data placement is specified as exact positions using a 10/6 grid -- 10 spaces per horizontal inch and 6 lines per vertical inch. Beginning grid position and maximum length of field is given in these specifications.

• ALL data MUST be within the template area . DO NOT print internal codes, date/time stamps, distribution information, etc . above the barcode or title of the form . This information may, however, be printed elsewhere on the form WITHIN the template . For more details on this, please contact Penny Widmer (see page 7 for contact information) .

Required fields - Data is required in ALL fields unless otherwise specified. Dollar amount fields should default to “0”. If specific data is indicated, use those restrictions when submitting samples. Example: If specifications state “Must be ‘001’ - ‘262’ or ‘999’”, do not enter “321” or “XXX” for sample-data or full-field forms.

Department ID Codes must be printed on the forms even if there is no data present for the corresponding line . Department ID Codes may be hard-coded as part of the template (blank form) or may be printed at the same time as the variable data .

Vendor ID Number - DATA - Each vendor that creates software that prints the variable data on forms will print their 4-digit ID number which is assigned by National Association of Computerized Tax Processors (NACTP) on

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DRAFT 21 NOV 2012each page on the bottom left corner . Data begins at grid 7/63 and ends at grid 10/63 . If you need an NACTP ID number, please contact NACTP via e-mail at [email protected] . In many cases, both the 2-digit (for barcode) and 4-digit Vendor ID numbers will identify the same company .

Data must be present in all fields with the following exceptions:If there is no Spouse or CU Partner, Spouse’s or CU Partner’s Name and Spouse’s or CU Partner’s Social

Security Number;If there is no paid preparer, Preparer’s SSN, PTIN and/or EIN; and,Other exceptions as described in each form specifications.

Do not allow more characters in the body of the form than is allowed by “Field Length”. Examples: 1) Do not allow 45 characters in the mailing address on the body of the form because the scanband only allows 35 characters . Taxpayer/preparer would need to abbreviate text; 2) Do not allow 7 or more digits in a dollar amount if the form only allows 6 digits . IMPORTANT: Dollar amounts on Form HI-144 MUST NOT exceed 6 digits!

Data alignments in scanband areas

Alpha fields should be aligned left. Alpha/Numeric fields should be aligned left. Numeric fields should be aligned right. Dollar amounts should be aligned right .

Punctuation and symbols should not be used in the scanband unless otherwise specified. Examples of UNACCEPTABLE punctuation: apostrophes (’), dashes or hyphens except for negative dollar amounts (-), decimal points or periods ( .), commas (,), dollar signs ($), number/pound signs (#), less than sign (<), greater than sign (>), etc . ACCEPTABLE punctuation: Percent sign (%) used as “in care of” in the address, hyphen (-) for negative dollar amounts only, and slash mark (/) used for fractions in the address . Examples:

UNACCEPTABLE ACCEPTABLE Show in scanband as:O’BRIEN OBRIEN (no apostrophe, no space)SMITH-JONES SMITH JONES (no hyphen, space instead)<1234> -1234 (use hyphen for negative dollar amounts)802-555-1234 8025551234 (no hyphens, no space)123-456-78901 12345678901 (no hyphens, no space)05609-1401 056091401 (no hyphen, no space)35 MAIN ST., APT. #4 35 MAIN ST APT 4 (no periods, no comma, no # sign)P. O. BOX 425 PO BOX 425 (no periods, no space between “P” & “O”)682 1/2 MAPLE AVE. 682 1/2 MAPLE AVE (no period)

Alpha characters must be ALL CAPITAL LETTERS in variable data fields. Department ID Codes will not vary between returns and, therefore, are exempt from this rule .

Dollar amounts must be rounded to the nearest whole dollar EXCEPT on Form RW-171 . (See Form RW-171 specifications on Pages 90-91 for further information .) The numbers in the scanband which show dollar amounts will be recorded as whole dollar amounts . Cents will not be shown in the scanband . Do not use decimal points . Example: $1,598 .00 in the taxpayer-readable portion of the form would be shown as “1598” in the scanband . Numbers should be aligned right . Default dollar amounts to “0” . Zeros are required in all empty or unused numeric fields on taxpayer-readable portion or Page 2 of each form.

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DRAFT 21 NOV 2012Percentages will be shown with the last two digits on the right indicating the two digits to the right of the decimal point . The decimal point will not be shown in the scanband . If the percentage does not have two digits to the right of the decimal point, add “0” to the end of the number to show these places . If the percentage shows two places to the right of the decimal point, those digits are used . Examples:

100% = 10000 62% = 6200 27 .8% = 2780 3 .5% = 350 74 .86% = 7486 4 .81% = 481

Foreign addresses should be printed within the specified field lengths, leaving state and ZIP Code fields blank, if necessary. The city and country can be printed in the “City” field, using a space between the city and country.

SUBMITTING FORMS FOR APPROVALWhen submitting forms for approval, please submit one blank form, one of each test case using the samples posted on our vendors-only website at www.state.vt.us/tax/vtvendors.shtml under “Paper Filing”, and one full-field form . Please include your e-mail address in your cover letter . We will give approval/disapproval via e-mail .

Blank forms must include the barcode, text and drawn lines on the form, and may include Department ID Codes . Blank forms must NOT have ANY variable data .

Sample data forms must be created using the test cases found on our vendors-only website . If our test cases are not used, then submitted forms will not be tested or approved . (See TEST CASES AND SAMPLE DATA on page 4 .)

Full-field forms are like those shown in these specifications. Each field is filled with numbers and/or letters to show the maximum field lengths while conforming to specifications. Example: If a field is a numeric field, do not fill with letters.

The sample forms should be sent to:

(via UPS, FedEx, DHL, etc., use:) (via US Mail, use:)Penny Widmer, Info Technology Specialist Penny Widmer, Info Technology SpecialistVermont Department of Taxes Vermont Department of Taxes133 State Street PO Box 429Montpelier, VT 05633-1401 Montpelier, VT 05601-0429

RELEASE OF PROGRAMVendors should notify the Department by e-mail ([email protected]) when their program is released .

MAILING COMPLETED RETURNSThe Department has two addresses for mailing completed Income tax returns (Personal Income tax returns only) . This is for use by the taxpayer(s) and tax preparer(s) . These addresses are not for submitting forms for approval prior to selling or using the software .

Returns with payment enclosed: Returns expecting a refund or no tax due:Vermont Department of Taxes Vermont Department of TaxesPO Box 1779 PO Box 1881Montpelier, VT 05601-1779 Montpelier, VT 05601-1881

QUESTIONS OR CONCERNSIf you have any questions or concerns about our Scanband Specifications for Individual Income forms, please feel free to contact Penny Widmer by e-mail at [email protected] or by phone at (802) 828-0684 .

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IN-111 Page

8

IN-111 Page

8

5432

DRAFT 21 NOV 2012Staple W-2/1099’s here 2012 VT INCOME TAX RETURN DUE DATE: April 15, 2013

FOR COMPUTERIZED USE ONLY

Form IN-111

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.

Your signature Date Occupation Preparer’s signature Date Print Firm’s name (or yours if self-employed) and address below Spouse or CU Partner signature. If a joint return, BOTH must sign. Date Occupation Taxpayer’s Telephone Number Spouse or CU Partner Telephone Number Preparer’s Telephone #

1. VT School Code 2. 911 street address on 12/31/2012

Your SSN

Spouse or CUPartner SSN

9. Exemptions Claimed

Taxpayer’s NameSpouse/CU Partner NameMailing AddressCity, State, ZIP

10 -123456789

11 -123456789

12a 123456789

12b 123456789

12c -123456789

13 -123456789

14a 123456789

14b 123456789

14c 123456789

14d 123456789

15 123456789

16 123456789

17 123456789

18 123456789

19 123456789

20 123456789

21 10000

22 123456789

23 123456789

24 123456789

25 123456789

26 123456789

27 123456789

28 123456789

29a 1234

29b 1234

29c 1234

29d 12345

30 123456789

31a 12345678

31b 12345678

31c 1234

31d 12345

31e 1234567

31f 1234567

31g 12345

31h 123456789

32 123456789

33a 12345678

33b 12345678

34 123456789

35 123456789

36 12345678

37 123456789

PTIN P23456789

PEIN 123456789

TY 2012 REC Y AMD N TDC N SDC N

DSC Y T65 N S65 Y FS P 000123456 EX 12

LASTNAMEXXXXXXXXXXXX FIRSTNAMEXXXXXXXXXXX I 000112233

SPLASTNAMEXXXXXXXXXX SPFIRSTNAMEXXXXXXXXX I 987654321

MAILING ADDRESS UP TO 35 CHARACTX35 CITYORTOWN TO TWENTY FIVE VT

051112241 012 911STREETADDRESSUPTO25XXX

REFUND 123456789 AMT DUE 123456789

PREPARER/FIRM NAMEPREPARER/FIRM ADDRESSCITY,STATE,ZIP 802-123-4567

802-123-7890 802-123-9876

LASTNAMEXXXXXXXXXXXX FIRSTNAMEXXXXXXXXXXX I 000-11-2233 SPLASTNAMEXXXXXXXXXX SPFIRSTNAMEXXXXXXXXX I MAILING ADDRESS UP TO 35 CHARACTX35 987-65-4321 CITYORTOWN TO TWENTY FIVE VT 051112241 12 012 911STREETADDRESSUPTO25XXX

*121113199** 1 2 1 1 1 3 1 9 9 *

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IN-111 Page

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IN-111 Page

9

5432

DRAFT 21 NOV 2012

For amended returns only Original refund received . . . . . . . . . . . . . . . . . Refund due now . . . . . . . . . . . . . . . . . . . . . . . Original payment . . . . . . . . . . . . . . . . . . . . . . . Amount due now . . . . . . . . . . . . . . . . . . . . . . .

2012 VT Form IN-111, Page 2 This page must be filed with Page 1 of this form.Last NameYour Social Security Number

Yes NoAre you using RECOMPUTED Federal Return Information?Is this an amended return? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Did Taxpayer die during 2012? . . . . . . . . . . . . . . . . . . . . . . . . . . . .Did Spouse/CU Partner die during 2012? . . . . . . . . . . . . . . . . . . . .Do you authorize the VT Department of Taxes to discuss this return with your preparer? . . . . . . . . . . . . . . . .Is Taxpayer age 65 or older as of December 31, 2012? . . . . . . . . .Is Spouse/CU Partner age 65 or older as of December 31, 2012? .

IN-111 Line-by-Line InformationSECTION 2 TAX FILING INFORMATIONFiling Status: Single Head of Household Qualifying Widow(er) Married, Filing Jointly Married, Filing Separately Civil Union, Filing Jointly Civil Union, Filing SeparatelyIF FILING SEPARATELY, Spouse or CU Partner Name

IF FILING SEPARATELY, Spouse or CU Partner Social Security Number

SECTION 3 TAXABLE INCOME10. Adjusted Gross Income . . . . . . . . . . . . . . . . . . . . . 10.11. Federal Taxable Income. If zero, see instructions 11.ADDITIONS:12a. Income from Non-VT State and Local Obligations

(Schedule IN-112, Part I, Line 3) . . . . . . . . . . . . . 12a.12b. Bonus Depreciation allowed under Federal law for 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12b.12c. Addback of State and Local Income Taxes (Schedule IN-154, Line 10) . . . . . . . . . . . . . . . . . 12c.13. Federal Taxable Income with Additions (Add Lines 11, 12a, 12b, and 12c) . . . . . . . . . . . . . 13.SUBTRACTIONS:14a. Interest Income from U.S. Obligations . . . . . . . . . 14a.14b. Capital Gains Exclusion . . . . . . . . . . . . . . . . . . . . 14b.14c. Adjustment for prior years’ Bonus Depreciation . 14c.14d. Add Lines 14a, 14b, and 14c. . . . . . . . . . . . . . . . 14d.15. VT Taxable Income (Subtract Line 14d from Line 13.

If Line 14d is more than Line 13, enter zero.) . . . . 15.SECTION 4 VT INCOME TAX16. VT Income Tax from VT Tax Table or Tax Rate Schedule on Line 15 amount . . . . . . . . . 16.17. Additions to VT Income Tax (Schedule IN-112, Part II, Line 7) . . . . . . . . . . . . . 17.18. VT Income Tax with Additions (Add Lines 16 & 17) 18.19. Subtractions from VT Income Tax (Schedule IN-112, Part II, Line 15) . . . . . . . . . . . . 19.20. VT Income Tax (Subtract Line 19 from Line 18) If Line 19 is more than Line 18, enter zero . . . . . . 20.21. Income Adjustment (Schedule IN-113, Line 43 OR 100.00%) . . . . . . . 21. %22. Adjusted VT Income Tax (Multiply Line 20 by Line 21) . . . . . . . . . . . . . . . . . 22.

Form IN-111

SECTION 5 CREDITS AND USE TAX23. Credit for Income Tax Paid to Other State or

Canadian Province (Schedule IN-117, Line 21) . . . 23.24. VT Tax Credits (Schedule IN-112, Part IV, Line 7 OR Schedule IN-119) . . . . . . . . . . . 24.25. Total VT Credits (Add Lines 23 and 24) . . . . . . . . . 25.26. VT Income Tax After Credits (Subtract Line 25 from Line 22, but not less than zero) . . . . . . . . . . . 26.27. Use Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.28. Total VT Taxes (Add Lines 26 and 27) . . . . . . . . . . 28.SECTION 6 VOLUNTARY CONTRIBUTIONS29a. Nongame Wildlife Fund . . . . . . . . . . . . . . . . . . . . 29a.29b. Children’s Trust Fund . . . . . . . . . . . . . . . . . . . . . . 29b.29c. VT Veterans’ Fund . . . . . . . . . . . . . . . . . . . . . . . . 29c.29d. Total Voluntary Contributions (Add Lines 29a through 29c) . . . . . . . . . . . . . . . . . . . . . . . . . 29d.30. Total of VT Taxes & Voluntary Contributions (Add Lines 28 and 29d) . . . . . . . . . . . . . . . . . . . . . 30.SECTION 7 PAYMENTS AND CREDITS31a. From W-2, 1099, etc. VT Tax Withheld . . . . . . . 31a.31b. From VT Form IN-114 Estimated Tax for 2012 and/or

VT Form IN-151, Extension with Payment . . . . . . 31b.31c. Earned Income Tax Credit (Schedule IN-112, Part III) . . . . . . . . . . . . . . . . . . 31c.31d. Renter Rebate (Form PR-141, Line 9). . . . . . . . . 31d.31e. From VT Form RW-171 VT Real Estate Withholding (see instructions) . . . . . . . . . . . . . . . 31e.31f. From VT Form WH-435 Estimated Income Tax Payment made by Business Entity for Nonresident Partner, Member, or Shareholder . . .31f.31g. Additional Refundable Credits. Documentation required (See instructions) . . . . . 31g.31h. Total Payments and Credits (Add Lines 31a through 31g) . . . . . . . . . . . . . . . . 31h.SECTION 8 REFUND32. OVERPAYMENT If Line 30 is less than Line 31h, subtract Line 30 from Line 31h. . . . . . . . 32.33a. Refund to be credited to 2013 estimated tax payment. Cannot use amount on Line 31d. . . . . 33a.33b. Refund to be credited to 2013 Property Tax Bill. . 33b.34. REFUND Amount (Subtract Lines 33a and 33b from Line 32). . . . . . 34.SECTION 9 AMOUNT YOU OWE35. If Line 30 is more than Line 31h, subtract Line 31h from Line 30. See instructions on tax due. . . . . . . 35.36. Interest and Penalty on Underpayment of Estimated Tax (Worksheet IN-152 or IN-152A) . . . 36.37. Add Lines 35 and 36 . . . . . . . . . . . . . . . . . . . . . . . 37.

To claim refund, mail to:VT Department of Taxes, PO Box 1881, Montpelier, VT 05601-1881

With payment, mail to:VT Department of Taxes, PO Box 1779, Montpelier, VT 05601-1779

SPOUSE’S NAME IF FILING SEPARATELY

000-12-3456

-123456789.-123456789.

123456789.

123456789.

-123456789.

-123456789.

123456789.123456789.123456789.123456789.

123456789.

123456789.

123456789.123456789.

123456789.

123456789.

100.00

123456789.

123456789.

123456789.123456789.

123456789.123456789.123456789.

1234.1234.1234.

12345.

123456789.

12345678.

12345678.

1234.12345.

1234567.

1234567.

12345.

123456789.

123456789.

12345678.12345678.

123456789.

123456789.

12345678.123456789.

Y N Y N Y N Y N

Y N Y N Y N

LASTNAMEXXXXXXXXXXXX 000112233

X X XX XX X

123456789.123456789.123456789.123456789.

[Page 10]

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2012 VT Tax Adjustments and Credits

Schedule IN-112


Taxpayer’s Last Name First Name Initial Taxpayer’s Social Security Number

IN-112 Line-by-Line Information

PART I ADJUSTMENT TO TAXABLE INCOME

I-1. Total interest and dividend income from all state and local obligations exempt from federal tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-1.I-2. Interest and dividend income from VT state and local obligations included in Line I-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-2.I-3. INCOME FROM NON-VT STATE AND LOCAL OBLIGATIONS TO BE ADDED TO VT TAXABLE INCOME. Subtract Line I-2 from Line I-1, but not less than zero. ENTER ON FORM IN-111, LINE 12a. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-3.

(IN-112 Line-by-Line Information continued on Page 2)Schedule IN-112

ATTACH TO FORM IN-111

SSN 000112233

I-1 1234567

I-2 1234567

I-3 1234567

II-1 1234567

II-2 1234567

II-3 1234567

II-4 12345678

II-5 12345678

II-6 12345678

II-7 12345678

II-8 1234567

II-9 1234567

II-10 1234567

II-11 1234567

II-12 12345678

II-13 12345678

II-14 12345678

II-15 12345678

III-A 00

III-B 00

III-C N

III-1 1234

III-2 1234

III-3A 12345

III-4A -12345

III-5A 12345

III-3B 12345

III-4B -12345

III-5B 12345

III-6 10000

III-7 1234

III-8 1234

III-9 1234

LASTNAMEXXXXXXXXXXXX FIRSTNAMEXXXXXXXXXXX I 000-11-2233

FEIN 123456789

IV-1A 123456

IV-2A 123456

IV-3A 123456

IV-4A 123456

IV-5A 123456

IV-6A 123456

IV-2B 0

IV-3B 123456

IV-4B 123456

IV-5B 123456

IV-6B 0

IV-1C 123456

IV-2C 123456

IV-3C 123456

IV-4C 123456

IV-5C 123456

IV-6C 123456

IV-7 123456

1234567.1234567.

1234567.

*121123199** 1 2 1 1 2 3 1 9 9 *

[Page 11]

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DRAFT 21 NOV 2012

IN-112 Line-by-Line Information (continued)

2012 Schedule IN-112, Page 2 This page must be filed with Page 1 of this schedule.Last NameYour Social Security Number

Schedule IN-112

Part II ADJUSTMENTS TO VT INCOME TAXAdditions to VT Tax:II-1. TaxonQualifiedPlansincludingIRA(1040-Line58 or Form 5329), HSA (Form 8889) and MSA (Form 8853) . . . .II-1.II-2. Recapture of Federal Investment Tax Credit (from Federal Form 4255) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .II-2.II-3. Tax from Federal Form 4972, Line 7 or 30 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .II-3.II-4. Add Lines II-1 through II-3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .II-4.II-5. Multiply Line II-4 by 24%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .II-5.II-6. Recapture of VT Credits (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .II-6.II-7. Add Lines II-5 and II-6. Enter on Form IN-111, Line 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II-7.Subtractions from VT Tax:II-8. Credit for Child and Dependent Care Expenses (1040-Line 48; 1040A-Line 29) . . . . . . . . . . . . . . . . . . . . . . . . . . .II-8.II-9. Credit for the Elderly or the Disabled (Federal Schedule R) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .II-9.II-10. Investment Tax Credit - VT-based only (from Federal Form 3468) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .II-10.II-11. VT Farm Income Averaging Credit (from worksheet) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II-11.II-12. Add Lines II-8 through II-11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .II-12.II-13. Multiply Line II-12 by 24% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .II-13.II-14. VT-based Business Solar Energy Credit carryforward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .II-14.II-15. Add Lines II-13 and II-14. Enter on Form IN-111, Line 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II-15.

Part III VT EARNED INCOME TAX CREDIT For FULL-YEAR residents and PART-YEAR residentsELIGIBILITY QUESTIONS - MUST BE ANSWERED III-A. Enter number of qualifying children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .III-A.III-B. Enter number of qualifying children under the age of 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .III-B.III-C. Wereyou(oryourspouseiffilingajointreturn)age25-65attheendof2012? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No If you answered “No” and do not have any qualifying children, you do not qualify for Earned Income Tax Credit.FULL-YEAR RESIDENTS: Answer eligibility questions above and complete Lines III-1 and III-2III-1. Earned income tax credit from Federal Form 1040, Line 64a; 1040A, Line 38a; or 1040EZ, Line 8a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III-1.III-2. VT EARNED INCOME TAX CREDIT (Multiply Line III-1 by 32%). Enter amount on Form IN-111, Line 31c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III-2.PART-YEAR RESIDENTS: Answer eligibility questions above and complete Lines III-3A through III-9 FEDERAL AMOUNT VT PORTIONIII-3A. Wages, salaries, tips, etc. (IN-113, Line 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III-3A. III-3B.III-4A. Other earned income (IN-113, Lines 6, 10, & 12) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III-4A. III-4B.III-5A. Total earned income (Add Lines III-3A & III-4A). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III-5A. III-5B.III-6. Earned Income Tax Credit adjustment (Divide Line III-5B by III-5A, but not more than 100.00%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III-6. %III-7. Earned Income Tax Credit from Federal Form 1040, Line 64a; 1040A, Line 38a; or 1040EZ, Line 8a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III-7.III-8. Multiply Line III-7 by 32%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III-8.III-9. VT EARNED INCOME TAX CREDIT (Multiply Line III-8 by Line III-6). Enter amount on Form IN-111, Line 31c . . . . . . . . . . . . . . . . . . . . . . . . . . . . III-9.

Part IV VT INCOME TAX CREDITSCredits for Lines IV-2 - IV-6 earned through an S-Corporation, LLC, LLP, or Partnership, enter name and FEIN of the entity.Name of Entity FEIN:Ifcreditsfrommorethanonebusinessentity,filloutaseparateScheduleIN-112,PartIVforeachentity. 2012 Contribution (C) CreditIV-1. VT Higher Education Investment (32 V.S.A. §5825a) . . . . . . . . . . . . . . . . . . . IV-1. TIMES (x) .10

(A) Earned in 2012 (B) Carryforward (C) CreditIV-2. Commercial Film Production (32 V.S.A. §5826) . . . . . . . . . . . . . . . . . . . . . . . IV-2. NOT AVAILABLEIV-3. Charitable Housing (32 V.S.A. §5830c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV-3.IV-4. QualifiedSaleofMobileHomePark(32V.S.A.§5828) . . . . . . . . . . . . . . . . . IV-4.IV-5. Research & Development (32 V.S.A. §5930ii) . . . . . . . . . . . . . . . . . . . . . . . . . IV-5.IV-6. Veteran Business Credit (32 V.S.A. §5930nn) . . . . . . . . . . . . . . . . . . . . . . . . . IV-6. NOT AVAILABLEIV-7. TOTAL CREDITS (Add Column C, Lines IV-1 - IV-6). If you have credits from Schedule IN-119 (see instructions), this amount is entered on Schedule IN-119. If you do NOT have credits from Schedule IN-119, enter this amount on Form IN-111, Line 24. . . . . . . . . . . . . . . . . . . . . . . .IV-7.


1234567. 1234567. 1234567. 12345678. 12345678. 12345678. 12345678.

1234567. 1234567. 1234567. 1234567. 12345678. 12345678. 12345678. 12345678.

00 00 X X

1234. 1234.

12345. 12345. -12345. -12345. 12345. 12345. 100.00 1234. 1234. 1234.

NAME OF ENTITY CREDITS EARNED THROUGH 123456789

123456. 123456.

123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456.

123456.

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DRAFT 21 NOV 2012


Schedule IN-113

2012 VT Income Adjustment Calculations

Schedule IN-113 ATTACH TO FORM IN-111Nonresidents and Part-Year Residents Must Complete Parts I and IIFull-Year Residents with Adjustments Complete Part II only


SSN 000112233

RESB 03212012

RESE 12312012

ST NC

1A 12345678

2A 12345678

3A 12345678

4A 12345678

5A 12345678

6A -12345678

7A -12345678

8A 12345678

9A 12345678

10A -12345678

11A -12345678

12A -12345678

13A 12345678

14A 12345678

15A -12345678

16A -12345678

17A 12345678

18A 12345678

19A 12345678

20A 12345678

21A 12345678

22A 12345678

23A 12345678

24A 12345678

25A 12345678

26A 12345678

27A 12345678

28A 12345678

1B 12345678

2B 12345678

3B 12345678

4B 12345678

5B 12345678

6B -12345678

7B -12345678

8B 12345678

9B 12345678

10B -12345678

11B -12345678

12B -12345678

13B 12345678

14B 12345678

15B -12345678

16B -12345678

17B 12345678

18B 12345678

19B 12345678

20B 12345678

21B 12345678

22B 12345678

23B 12345678

24B 12345678

25B 12345678

26B 12345678

27B 12345678

28B 12345678

29 -12345678

30 -12345678

31 -12345678

32 -12345678

33 -12345678

34 12345678

35 12345678

36 12345678

37 12345678

38 12345678

39 12345678

40 12345678

41 -12345678

42 -12345678

43 10000


VSAC Y

BA Y

TEL Y

PSA N

*121133199** 1 2 1 1 3 3 1 9 9 *

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5432

DRAFT 21 NOV 20122012 Schedule IN-113, Page 2 This page must be filed with Page 1 of this schedule.Last NameYour Social Security Number

PART I. Enter figures as they appear on your federal return or recomputed federal return in Column A and list the VT portion in Column B. See instructions.Dates of VT residency in 2012: From toName of state or Canadian province. Use standard two-letter abbreviation:INCOME A. FEDERAL AMOUNT $ B. VT PORTION $1. Wages, salaries, tips, etc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1A. 1B.2. Taxable interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2A. 2B.3. Ordinary dividends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3A. 3B.4. Taxable refunds of state and local income taxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4A. 4B.5. Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5A. 5B.6. Business income or loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6A. 6B.7. Capital gain or loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7A. 7B.8. Taxable IRA distributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8A. 8B.9. Taxable pensions and annuities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9A. 9B.10. Partnerships/S Corporations & LLCs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10A. 10B.11. Rents, royalties, estates, trusts, etc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11A. 11B.12. Farm income or loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12A. 12B.13. Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13A. 13B.14. Taxable social security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14A. 14B.15. Other. Specify: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15A. 15B.16. TOTAL INCOME (Add Lines 1 - 15) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16A. 16B.ADJUSTMENTS TO INCOME17. IRA (1040, Line 32; or 1040A, Line 17); Keogh/SEP/SIMPLE (1040, Line 28): Self Spouse 17A. 17B.18. Student Loan Interest (1040-Line 33; 1040A-Line 18). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18A. 18B.19. Employee Deductions:Reservists,PerformingArtists,Fee-basisGov’tOfficials (1040-Line 24) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19A. 19B.20. Self-Employment Deductions: Tax (1040-Line 27), and Health Insurance (1040-Line 29) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20A. 20B.21. Health Savings Account (1040-Line 25) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21A. 21B.22. Moving Expenses (1040-Line 26) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22A. 22B.23. Penalty on Early Withdrawal of Savings (1040-Line 30) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23A. 23B.24. Alimony Paid (1040-Line 31a) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24A. 24B.25. Domestic production activities (1040-Line 35) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25A. 25B.26. Educator Expenses (1040-Line 23; 1040A-Line 16), and Tuition & Fees (1040-Line 34; 1040A-Line 19) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26A. 26B.27. Deductions not listed above but included on 1040-Line 36 . . . . . . . . . . . . . . . . . . . . . . . . . . 27A. 27B.28. TOTAL ADJUSTMENTS (Add Lines 17 - 27) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28A. 28B.29. Adjusted Gross Income (Subtract Line 28A from Line 16A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29.30. VT Portion of AGI (Subtract Line 28B from Line 16B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.31. Non-VT Income (Subtract Line 30 from Line 29.) Also enter on Part II, Line 33 below. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.

PART II. Adjustment for VT Exempt Income32. Adjusted Gross Income If Part I completed, enter Line 29. Otherwise, enter amount from Form IN-111, Line 10. . . . . . . . . . . . . . . . . . . . . 32.33. Non-VT Income (Enter amount from Line 31 above) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33. (Full-year VT residents enter 0 on Line 33) (Part-Year Residents: For Lines 34 - 40, enter only income included in Part I, Line 30)34. Military pay. Number of months on active duty . . . . . . . . . . . . . . . . . . . . . . . 34.35. Federal Employment Opportunity income adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.36. Railroad Retirement income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.37. VT State payments to a family for support of developmentally disabled person(s) . . . . . . . . . 37.38. Americans with Disabilities Credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38.39. Nonresident Commercial Film Income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39.40. Bond/note interest income from . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40. VSAC Build America VT Telecom Authority VT Public Power Supply Authority41. Total (Add Lines 33 - 40) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.42. VT Income (Subtract Line 41 from Line 32) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42.43. INCOME ADJUSTMENT % (Divide Line 42 by Line 32). Also enter on Form IN-111, Line 21. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43. %

Schedule IN-113

03 21 2012 12 31 2012 NC 12345678. 12345678. 12345678. 12345678. 12345678. 12345678. 12345678. 12345678. 12345678. 12345678. -12345678. -12345678. -12345678. -12345678. 12345678. 12345678. 12345678. 12345678. -12345678. -12345678. -12345678. -12345678. -12345678. -12345678. 12345678. 12345678. 12345678. 12345678. SPECIFY OTHER INCOME HERE -12345678. -12345678. -12345678. -12345678.

12345678. 12345678. 12345678. 12345678. 12345678. 12345678.

12345678. 12345678.

12345678. 12345678. 12345678. 12345678. 12345678. 12345678. 12345678. 12345678. 12345678. 12345678. 12345678. 12345678.

12345678. 12345678. 12345678. 12345678. 12345678. 12345678. -12345678. -12345678. -12345678.

-12345678. -12345678. 12 12345678. 12345678. 12345678. 12345678. 12345678. 12345678. 12345678. X X X X -12345678. -12345678. 100.00


[Page 14]

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14

5432

DRAFT 21 NOV 2012 VERMONT Form IN-114

Individual Income Estimated Tax Payment Voucher

Form IN-114

Cut at line above. Mail top portion with check or money order to: Vermont Department of Taxes, PO Box 1779, Montpelier, VT 05601-1779Keep this portion for your records.

Form IN-114

KEEP THIS PORTION FOR YOUR RECORDS

MAIL TOP PORTION WITH YOUR PAYMENT

VERMONT Form IN-114


TAXPAYER’S COPYTaxpayer’s Last Name First Name Initial Taxpayer’s Social Security Number

Spouse or CU Partner Last Name First Name Initial Spouse or CU Partner Social Security Number

Mailing Address (Number and Street, including Rural Route)

City,Town,orPostOffice State ZIPCode

Amount of this payment $

MAIL VOUCHER TO: Vermont Department of Taxes PO Box 1779 Montpelier, VT 05601-1779

Amount of this payment

$

PAYMENT DUE DATES: 1st Quarter APR 15, 2013 2nd Quarter JUN 15, 2013 3rd Quarter SEP 15, 2013 4th Quarter JAN 15, 2014

TY 2013 AMT 1234567



MAILING ADDRESS UP TO 35 CHARACTX35

CITYORTOWN TO TWENTY FIVE VT 051112241

1234567.

5432





1234567.

2013

2013

*101143199** 1 0 1 1 4 3 1 9 9 *

[Page 15]

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DRAFT 21 NOV 2012 VERMONT


$

Make check payable to: VERMONT DEPARTMENT OF TAXES

VERMONT






Use this form if you are NOT submitting payment with Form IN-111.


Form IN-116



Income Tax Payment Voucher Form IN-116


Form IN-116

TY 2012 AMT 123456789




CITYORTOWN TO TWENTY FIVE VT 051112241 123456789.

5432





123456789.

2012

2012*081163199** 0 9 1 1 6 3 1 9 9 *

[Page 16]

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5432

DRAFT 21 NOV 20122012 VT Credit for Income Tax Paid to Other State or Canadian Province Schedule IN-117


1. Name of state or Canadian province. Use standard two-letter abbreviation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. 2. Enter Adjusted Gross Income taxed in another state or Canadian province

that is also subject to VT income tax. This entry cannot be more than entry on Form IN-111, Line 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.

3. 2012 Bonus Depreciation add back taxed in another state or Canadian province AND taxed in VT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.

4. Non-VT state/local obligations taxed in another state or Canadian province AND taxed in VT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.

5. Add Lines 2-4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. 6. Bonus Depreciation subtracted from income in another state or

Canadian province in tax year 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. 7. U. S. Government interest income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. 8. Add Lines 6 & 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 9. ModifiedAdjustedGrossIncomeforincometaxedinotherstateorCanadianprovinceANDtaxedin

VT (Subtract Line 8 from Line 5). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. 10. Adjusted Gross Income from Form IN-111, Line 10 . . . . . . . . . . . . . . . . . . . . 10. 11. Non-VT state/local obligations from Form IN-111, Line 12a. . . . . . . . . . . . . . .11. 12. Bonus Depreciation from Form IN-111, Line 12b . . . . . . . . . . . . . . . . . . . . . . 12. 13. Add Lines 10-12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13. 14. U.S. Government interest income from Form IN-111, Line 14a . . . . . . . . . . . 14. 15. Bonus Depreciation from Form IN-111, Line 14c. . . . . . . . . . . . . . . . . . . . . . 15. 16. Add Lines 14 & 15. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.17. Subtract Line 16 from Line 13. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17. 18. VT income tax from Form IN-111, Line 20. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18. 19. Computed tax credit (Divide Line 9 by Line 17 and multiply result by Line 18).

Result cannot be more than 100% of VT tax. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. IncometaxpaidtoanotherstateorCanadianprovincebasedonmodifiedadjustedgrossincomefrom

Line 9 above. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20. 21. VT CREDIT for income tax paid to another state or Canadian province. Enter the lesser of Line 19 or Line 20.

Also enter on Form IN-111, Line 23. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.

For Residents and Some Part-Year Residents ONLY.You must complete a separate Schedule IN-117 for each state or Canadian provinceand attach a copy of the other state return(s). See instructions. ATTACH TO FORM IN-111


Schedule IN-117

SSN 000112233

1 NC

2 -123456789

3 123456789

4 123456789

5 123456789

6 123456789

NC

-123456789.

123456789.

123456789. 123456789.

123456789. 123456789. 123456789.

123456789. -123456789. 123456789. 123456789. 123456789. 123456789. 123456789. 123456789. 123456789. 123456789.

123456789.

123456789.

123456789.

7 123456789

8 123456789

9 123456789

10 -123456789

11 123456789

12 123456789

13 123456789


14 123456789

15 123456789

16 123456789

17 123456789

18 123456789

19 123456789

20 123456789

21 123456789

*121173199** 1 2 1 1 7 3 1 9 9 *

[Page 17]

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DRAFT 21 NOV 2012


For credits earned through an S-Corporation, LLC, LLP, or Partnership, enter name and FEIN of the entity. Name of entity FEIN

Ifcreditsfrommorethanonebusinessentity,filloutaseparateIN-119foreachentity.

Schedule IN-119

2012 VT Tax Credits Schedule IN-119 ATTACH TO FORM IN-111


SSN 000112233

FEIN 123456789

1A 123456

2A 123456

3A 123456

4A 123456

5A 123456

6A 123456

7A 123456

8A 123456

9A 123456

1B 123456

2B 123456

3B 123456

4B 123456

5B 123456

6B 123456

7B 123456

8B 123456

9B 123456

1C 123456

2C 123456

3C 123456

4C 123456

5C 123456

6C 123456

7C 123456

8C 123456

9C 123456

10 123456

11 123456

12 123456

13 123456

14C 123456

15C 123456

16C 123456

17C 123456

18C 123456

19C 123456

20C 123456

21C 123456

22 123456

23 123456789

24 123456789

25 123456789

26 123456789

27 123456789

28 123456789

29 123456789

30 123456789

31 123456789

32 123456789

33 123456789

34 123456789

35 123456789

36 123456789

37 123456789

38 10000

39 123456789

40 123456789

41 123456789

42 123456789

43 123456789

44 123456789


NAME OF ENTITY IF CREDITS EARNED THROUGH IT 123456789

*121193199** 1 2 1 1 9 3 1 9 9 *

[Page 18]

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DRAFT 21 NOV 20122012 Schedule IN-119, Page 2 This page must be filed with Page 1 of this schedule.Last Name Name of EntityYour Social Security Number FEIN:

Schedule IN-119

IN-119 Line-by-Line Information ALL CREDITS REQUIRE PRIOR APPROVAL

Tax Credit Calculation Worksheet 23. Enter adjusted VT income tax amount from Form IN-111, Line 22 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23. 24. Enter credit for income tax paid to another state or Canadian province from Form IN-111, Line 23 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24. 25. Subtract Line 24 from Line 23 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25. 26. Enter the amount from Line 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26. 27. Enter the amount from Line 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27. 28. Add Lines 26 and 27 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28. 29. Enter the smaller of Line 25 OR Line 28.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29. 30. Subtract Line 29 from Line 25, but not less than zero. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30. 31. Multiply Line 30 by 50%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31. 32. Enter amount from Line 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32. 33. Enter the smaller of Line 31 or Line 32 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33. 34. Subtract Line 33 from Line 30, but not less than zero. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34.Complete Lines 35-42 if claiming Economic Advancement Tax Incentive (EATI) Carry forward credits. Otherwise go to Line 43. 35. VT tax from Form IN-111, Line 22 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.Ratio Schedule K-1 to Adjusted Gross Income 36. Schedule K-1 income from entity with EATI credit(s). If EATI credits from more than one entity, see instructions. If negative, enter “0” here and on Line 38. . . . . . . . . . . . 36. 37. Adjusted Gross Income Resident: Form IN-111, Line 10; Nonresident: Schedule IN-113, Line 42. If negative, enter “0” here and on Line 38. . . . . . . 37. 38. Divide Line 36 by Line 37 but not greater than 100.00%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38. % 39. VT Tax attributable to Schedule K-1 Income (Multiply Line 35 by Line 38) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39. 40. Statutory Credit Limitation (Multiply Line 39 by 80%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40. 41. Credit Claimed. Enter amount from Line 22. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41. 42. Maximum allowable EATI Credit (Enter the smaller of Line 40 or Line 41). If EATI credits from more than one entity, see instructions. . . . . . . . . . . . 42. 43. Total Credits Allowable. Enter the total of Lines 29, 33 and 42. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43. 44. TOTAL INCOME TAX CREDITS AVAILABLE. Enter the smaller of Line 25 or Line 43. Enter this amount on Form IN-111, Line 24. . . . . . . . . . . . . 44.

ECONOMIC ADVANCEMENT TAX INCENTIVE CARRY FORWARD CREDITS Lines 14-21 require prior approval from VT Economic Progress Council 14. Payroll, 32 V.S.A. §5930c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14. 15. Research & Development, 32 V.S.A. §5930d . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15. 16. Capital Investment, 32 V.S.A. §5930g . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16. 17. Workforce Development, 32 V.S.A. §5930e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17. 18. Export, 32 V.S.A. §5930f . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18. 19. High-Tech Growth, 32 V.S.A. §5930k . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. Sustainable Technology R & D, 32 V.S.A. §5930w . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20. 21. Sustainable Technology Export, 32 V.S.A. §5930x . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21. 22. Add Lines 14-21. Go to worksheet below to calculate the credit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.

Column A PLUS (+) Column B EQUALS (=) Column C Earned in 2012 Carryforward 2012 CreditPrior approval required from VT Housing Finance Agency for Line 1 1. Affordable Housing, 32 V.S.A. §5930u . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.Prior approval required from VT Division for Historic Preservation for Lines 2-8 2. RehabilitationofCertifiedHistoricBuildings,32V.S.A.§5930n . . . . . . . . . . . . . . . . . . . . . . . . 2. 3. Older or Historic Buildings Rehabilitation, 32 V.S.A. §5930p . . . . . . . . . . . . . . . . . . . . . . . . . . 3. 4. Commercial Building Code Improvements, 32 V.S.A. §5930r . . . . . . . . . . . . . . . . . . . . . . . . . . 4. 5. Platform Lifts, Elevators, and Sprinkler Systems, 32 V.S.A. §5930q . . . . . . . . . . . . . . . . . . . . . 5. 6. Historic Rehabilitation, 32 V.S.A. §5930cc(a) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. 7. Facade Improvement, 32 V.S.A. §5930cc(b) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. 8. Code Improvements, 32 V.S.A. §5930cc(c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 9. Wood Products Manufacture, 32 V.S.A. §5930y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. 10. Add Column C, Lines 1-9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10. 11. Enter amount from Schedule IN-112, Part IV, Line 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 12. Add Lines 10 & 11. If no credits from Lines 13-21, enter amount on Form IN-111, Line 24. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 13. VT Entrepreneur’s Seed Capital Fund, 32 V.S.A. §5830b. Go to worksheet below to calculate the credit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.

123456. 123456. 123456.

123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456.

LASTNAMEXXXXXXXXXXXX ENTITY CREDITS EARNED THROUGH 000112233 123456789

123456789. 123456789. 123456789. 123456789. 123456789. 123456789. 123456789. 123456789. 123456789. 123456789. 123456789. 123456789.

123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456. 123456.

123456789.

123456789.

123456789. 100.00 123456789. 123456789. 123456789. 123456789. 123456789. 123456789.

[Page 19]

HS-122 Page

19

HS-122 Page

19

5432

DRAFT 21 NOV 20122013 VT Homestead Declaration AND Property Tax Adjustment Claim Form HS-122

DUE DATE: April 15, 2013(ClaimsalloweduptoOctober15,2013butlatefilingpenaltiesapply)This form can be filed on-line at http://tax.vermont.gov

Check here if authorizing the VT Department of Taxes to discuss this return and attachments with your preparer.

Form HS-122


1. VT School District Code 2. City/Town of Legal Residence on 04/01/2013 State

Location of Homestead (number, street/road name DO NOT use PO Box, “same”, or Town name) 3. SPAN Number (REQUIRED)

(From your property tax bill)

Claimant’s NameSpouse/CU Partner NameMailing AddressCity, State, ZIP

Claimant’sSSN

Spouse or CUPartner SSNClaimant’s Date of Birth

Homeowner signature Date Preparer’s signature Date Print Firm’s name (or yours if self-employed) and address below

If a joint return, Spouse or CU Partner must sign Date Taxpayer’s Telephone Number Spouse or CU Partner Telephone Number Preparer’s Telephone Number


LASTNAMEXXXXXXXXXXXX FIRSTNAMEXXXXXXXXXXX I 000112233 SPLASTNAMEXXXXXXXXXX SPFIRSTNAMEXXXXXXXXX I MAILING ADDRESS UP TO 35 CHARACTX35 000223345 CITYORTOWN TO TWENTY FIVE VT 051112241 01/01/1968 012 CITY OR TOWN OF LEGALXXXX VT

STREET ADDRESS OF HOMESTEAD UPTO 35 123-456-78901

X

802-123-7890 802-123-9876

PREPARER’S NAMEPREPARER’S STREET ADDRESSPREPARER’S CITY,STATE,ZIP 802-123-4567

TY 2013 DSC Y DOB 01011968





012 CITY OR TOWN OF LEGALXXXX VT SPAN 12345678901

LOC STREET ADDRESS OF HOMESTEAD UPTO 35

A4 10000

A5 10000

A6 N

A7 N

A8 N

A9 N

A10 N

B1 Y

B2 N

B3 N

B4 1234567

B5 12345

B6 12345

B7 10000

B8 123456

B8a N

B9 12345

B10 12345

B11 12345

B12 12345

B13 12345

PTIN P23456789

PEIN 123456789

*131223199** 1 3 1 2 2 3 1 9 9 *

[Page 20]

HS-122 Page

20

HS-122 Page

20

5432

DRAFT 21 NOV 20122013 Form HS-122, Page 2 This page must be filed with Page 1 of this form.Last NameYour Social Security Number

SECTION A ANNUAL Vermont Homestead Declaration This form must be filed EACH YEAR by ALL VT residents who own and occupy a VT homestead on April 1 even if a claim for

property tax adjustment is not made.

A4. Business Use of Dwelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A4. %A5. Rental Use of Dwelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A5. %A6. 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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A6. Yes NoA7-A10 Special Situations (see instructions for more information) A7. Areyougrantorandsolebeneficiaryofarevocabletrustowningtheproperty? . . . . . . . . . . . . . . . . . . . A7. Yes No A8. Are you life estate holder of the property? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A8. Yes No A9. Doesyourhomesteadcrosstownboundaries?If“Yes”,youmustfileadeclarationforeachtown . . . . A9. Yes No A10. Are you residing in a dwelling owned by a related farmer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A10. Yes No

IMPORTANT FILING INFORMATION• IfyouwillnotbefilingaPropertyTaxAdjustmentClaim,pleasesignpage1ofthisreturn.• If you willbefilingaPropertyTaxAdjustmentClaim,continueontocompleteSectionB.

Form HS-122

HS-122 Line-by-Line Information

SECTION B PROPERTY TAX ADJUSTMENT CLAIM For Household Income up to approx. $99,000. Attach Schedule HI-144.

All eligibility questions must be answered. You must own and occupy the property as your home on April 1, 2013.B1. Were you domiciled in VT all of calendar year 2012? . . . . . . . . . . . . . . . . . . . B1. Yes, Go to Line B2. No, STOPB2. Were you claimed as a dependent in 2012 by another taxpayer?. . . . . . . . . . B2. Yes, STOP No, Go to Line B3.B3. Do you anticipate selling your VT housesite on or before April 1, 2013? . . . . B3. Yes, STOP No, CONTINUE

Amounts for Lines B4 - B6 are found on your 2012/2013 property tax bill. Round amounts to the nearest dollar.B4. Housesite Value . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B4.B5. Housesite Education Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B5.B6. Housesite Municipal Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B6.B7. Ownership Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B7. %B8. Household Income (Schedule HI-144, Line y) Schedule HI-144 MUST be attached. . . . . . . . . . . . . . . . . . . B8. B8a. Is AMENDED SCHEDULE HI-144, Household Income, attached? . . . . . . . . . . . . . . . . . . . . . . . . . . . . B8a. Yes No

Complete the following ONLY if applicable. See instructions for details.Lot Rent B9. Mobile Home Lot Rent (LC-142, Line 16) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B9.

OR Allocated Property Tax from Land Trust, Cooperative, or Nonprofit Mobile Home Park B10. Allocated Education Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B10. B11. Allocated Municipal Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B11.

OR Property Tax from contiguous property if housesite has less than 2 acres (see instructions) B12. Contiguous property Education Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B12. B13. Contiguous property Municipal Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B13.

MAXIMUM ADJUSTMENT AMOUNT IS $8,000

Mail to: VT Department of Taxes PO Box 1881 Montpelier, VT 05601-1881

To file a Homestead Declaration: Please complete Section A, sign below and send to the Department.To file a Property Tax Adjustment Claim: Please complete Section A and Section B, sign below and send to the Department together with a completed

HI-144 Household Income schedule. You will not receive a Property Tax Adjustment unless you file a Homestead Declaration, a Property Tax Adjustment Claim, and a Household Income schedule no later than October 15, 2013.


34.00 12.00

X X

X X X X X X X X

X X X X X X

1234567.0012345.0012345.00100.00

123456.00 X X

12345.00

12345.0012345.00

12345.0012345.00

[Page 21]

PR-141 Page

21

PR-141 Page

21

5432

DRAFT 21 NOV 20122012 VT Renter Rebate Claim Form PR-141 FOR HOUSEHOLD INCOME OF $47,000 OR LESSFor the year Jan. 1 - Dec. 31, 2012DUE DATE: April 15, 2013 (Claims allowed up to Oct. 15, 2013)

Form PR-141


Check here if authorizing the Vermont Department of Taxes to discuss this return and attachments with your preparer.

REBATE CALCULATION. Before doing rebate calculation, complete Household Income (Schedule HI-144).3. ALLOCABLE RENT (LC-142, Line 16) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4. HOME USE. If more than 25% of this rental is used for business, see instructions. If not, enter 100.00%. 4. %5. ALLOWABLE RENT FOR REBATE CLAIM (Multiply Line 3 by Line 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.6. HOUSEHOLD INCOME (From Schedule HI-144, Line y) If more than $47,000, you are not eligible. . . . . . 6. 6a. If AMENDED SCHEDULE HI-144, Household Income, is attached, check here. . 7. MAXIMUM PERCENTAGE OF INCOME FOR RENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. % If Line 6 Household Income is: $0 - 9,999 $10,000 - 24,999 $25,000 - 47,000 Enter this % on Line 7: 2.00% 4.50% 5.00%8. MAXIMUM RENT FOR HOUSEHOLD INCOME (Multiply Line 6 by Line 7 and enter result here) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. If Line 8 is more than Line 5, you do not qualify for a renter rebate.9. RENTER REBATE AMOUNT(SubtractLine8fromLine5andenterresulthere.)Ifresultiszero,youdonotqualifyforarebate.Iffilingthis form with the VT Income Tax Return, also enter this amount on Form IN-111, Line 31d.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.

MAXIMUM REBATE AMOUNT IS $3,000. ATTACH SCHEDULE HI-144 AND LC-142.

Claimant’s SSN


Claimant’sDate of Birth




Your signature Date Preparer’s signature Date Print Firm’s name (or yours if self-employed) and address below

Spouse or CU Partner signature. If a joint return, BOTH must sign. Date Claimant’s Telephone Number Spouse or CU Partner Telephone Number Preparer’s Telephone Number

MAIL TO: Vermont Department of Taxes, PO Box 1881, Montpelier, VT 05601-1881

Must Be Filed With: Household Income (Schedule HI-144) and Landlord’s Certificate (LC-142)

Location of rental property (number, street/road name DO NOT use PO Box, “same”, or Town name)ALL eligibility questions must be answered. You must have rented all 12 months in 2012. See instructions for exception.Q1. Were you domiciled in VT all of calendar year 2012? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes, Go to Q2. No, STOP. You are not eligible.Q2. Were you claimed as a dependent by another taxpayer in 2012? . . . . . . . . . . . . . . . . . . . . Yes, STOP. You are not eligible. No, Go to Q3.Q3. Did you rent in VT all 12 months in calendar year 2012? . . . . . . . . . . . . . . . . . . . . . . . . . . Yes, Complete this form. No, STOP. You are not eligible.

12345. 100.00 12345. 12345. X 4.50

12345.

12345.

LASTNAMEXXXXXXXXXXXX FIRSTNAMEXXXXXXXXXXX I 000112233 SPLASTNAMEXXXXXXXXXX SPFIRSTNAMEXXXXXXXXX I MAILING ADDRESS UP TO 35 CHARACTX35 000223345 CITYORTOWN TO TWENTY FIVE VT 051112241 06/20/1942 012 CITY OR TOWN OF LEGALXXXX VT STREET ADDR OF PROP21

X X X X X X

TY 2012 DSC Y DOB 06201942 6a Y



MAILING ADDRESS UP TO 35 CHARACTX35 CITYORTOWN TO TWENTY FIVE VT

051112241 012 CITY OR TOWN OF LEGALXXXX VT

LOC STREET ADDR OF PROP21 Q1 Y Q2 N Q3 Y

3 12345 4 10000 5 12345 6 12345 7 450

8 12345 9 12345 PTIN P23456789 PEIN 987654321

802-123-7890 802-123-9876

PREPARER’S NAMEPREPARER’S STREET ADDRESSPREPARER’S CITY,STATE,ZIP 802-123-4567

X

*121413199** 1 2 1 4 1 3 1 9 9 *

[Page 22]

HI-144 Page

22

HI-144 Page

22

5432

DRAFT 21 NOV 2012


Schedule HI-144

2012 VT Household Income Schedule HI-144

For the year Jan. 1 - Dec. 31, 2012This schedule must be attached to the 2012 Renter Rebate Claim (Form PR-141) OR the

2013 Property Tax Adjustment Claim (Form HS-122) UNLESS you are filing an AMENDED HI-144. Please read instructions before completing schedule.

Claimant’s Last Name First Name Initial Claimant’s Social Security Number

Claimant’s Date of Birth (MMDDYYYY)

1a 123456

1b 123456

1c 123456

1d 123456

1e 123456

1f 123456

1g 123456

1h 123456

1i 123456

1j 123456

1k 123456

1l 123456

1m 123456

1n 123456

2a 123456

2b 123456

2c 123456

2d 123456

2e 123456

2f 123456

2g 123456

2h 123456

2i 123456

2j 123456

2k 123456

2l 123456

2m 123456

2n 123456

3a 123456

3b 123456

3c 123456

3d 123456

3e 123456

3f 123456

3g 123456

3h 123456

3i 123456

3j 123456

3k 123456

3l 123456

3m 123456

3n 123456

1o 123456

1p 123456

1q1 123456

1q2 123456

1q3 123456

1q4 123456

1q5 123456

1r 123456

1s 123456

1u 123456

2o 123456

2p 123456

2q1 123456

2q2 123456

2q3 123456

LASTNAMEXXXXXXXXXXXX FIRSTNAMEXXXXXXXXXXX I 000-11-2233 06201942

2q4 123456

2q5 123456

2r 123456

2s 123456

2u 123456

3o 123456

3p 123456

3q1 123456

3q2 123456

3q3 123456

3q4 123456

3q5 123456

3r 123456

3s 123456

3t 123456

3u 123456

3v 123456

3w 10000

3x 123456

3y 123456

SSN 000112233

OP1 OTHERPERSONONELAST20 FIRSTNAMEXXXX15 I 222334567

OP2 OTHERPERSONTWOLAST20 FIRSTNAMEXXXX15 I 333456789

SPD SUPPORTPAIDTONAME20X SPDSSN 987654321

*121443199** 1 2 1 4 4 3 1 9 9 *

[Page 23]

HI-144 Page

23

HI-144 Page

23

5432

DRAFT 21 NOV 2012

HI-144 Line-by-Line InformationList the names and Social Security Numbers of all other persons (other than a Spouse or CU Partner) who had income and lived with you during 2012. Include their income in column 3.Ifyouhavemorethantwo“OtherPersons”livinginyourhousehold,recordthenamesandsocialsecuritynumbersonaseparatesheetofpaperandincludewiththefiling. Last Name First Name Initial Social Security NumberOther Person #1Other Person #2

2012 Schedule HI-144, Page 2 This page must be filed with Page 1 of this schedule.Last NameYour Social Security Number

Schedule HI-144

a. Cash public assistance and relief a. a. a.b. Social security/railroad retirement/veteran’s benefits, taxable and

nontaxable b. b. b.c. Unemployment compensation/worker’s compensation c. c. c.d. Wages, salaries, tips, etc. (See instructions for dependent’s exempt

income.) d. d. d.e. Interest and dividends e. e. e.f. Interest on U.S., state, and municipal obligations, taxable and

nontaxable f. f. f.g. Alimony, support money, child support, cash gifts g. g. g.h. Business income: If the amount is a loss, enter zero. See

instructions for offsetting a loss. h. h. h.i. Capital gains, taxable and nontaxable. If the amount is a loss,

enter zero. See instructions for offsetting a loss. i. i. i.j. Taxable pensions, annuities, IRA and other retirement fund

distributions. See instructions. j. j. j.k. Rental and royalty income: If the amount is a loss, enter zero.

See instructions for offsetting a loss. k. k. k.l. Farm/partnerships/S Corporations/LLC/Estate or Trust Income: If the

amount is a loss, enter zero. See Line i instructions for only exception to offset a loss.

l. l. l.m. Other income. (See instructions for examples of other income).

Please specify. m. m. m.n. TOTAL INCOME Add Lines a through m n. n. n.

o. See instructions. Enter Social Security and Medicare tax withheld on wages. 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. Attach W-2 and/or Federal Schedule SEifnotincludedwithincometaxfiling.

o. o. o.p. Child support paid. You must attach proof of payment. See

instructions. Support paid to:

SSN: p. p. p.q. Allowable Adjustments from Federal Form 1040 or 1040A q1. Business Expenses for Reservists (1040, Line 24) q1. q1. q1. q2. Alimony paid (1040, Line 31a) q2. q2. q2. q3. Tuition and Fees (1040, Line 34 or 1040A, Line 19) q3. q3. q3. q4.Self-employed health insurance deduction (1040, Line 29) q4. q4. q4. q5.Health Savings account deduction (1040, Line 25) q5. q5. q5. r. Add Lines o, p and the total of Lines q1 to q5 for each column. r. r. r.s. Subtract Line r from Line n of each column. If negative, enter zero. s. s. s.t. Add all three amounts from Line s.

If negative, enter zero. . . . . . . . . . . . . . . . . . . . . .t.u. Complete if born 1/1/1948 and after Enter interest and dividend income from Lines e and f. u. u. u.v. Add all three amounts from Line u. . . . . . . . . . . . .v.w. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .w.x. Subtract Line w from Line v.

If Line w is more than Line v, enter zero (0). . . . . .x.y. HOUSEHOLD INCOME. Add Line t and Line x . .y.

1. Claimant 2. Spouse/ 3. Other CU Partner Persons

RENTERS: If Line y Household Income is $47,000 or less, you may be eligible for a renter rebate. Complete Form PR-141. This schedule mustbefiledwiththeRenterRebateClaim.ClaimsaredueApril15,2013butcanbefileduptoOctober15,2013.

If Household Income is more than $47,000, you do not qualify for a renter rebate.HOMEOWNERS: Form HS-122, Property Tax Adjustment Claim,mustbefiledeachyear. Homeowners with Household Income up to $99,000 on Line y should complete Form HS-122 Section B. You may be

eligibleforapropertytaxadjustment.ThisschedulemustbefiledwiththeHS-122. Form HS-122 Due Date - April 15, 2013.HomeownersfilingacompletedHS-122andHI-144betweenApril16andOctober15,

2013maystillqualifyforapropertytaxadjustment.A$15latefilingpenaltywillbedeductedfromtheadjustment.

1. Claimant 2. Spouse/ 3. Other CU Partner Persons

OTHERPERSONONELAST20 FIRSTNAMEXXXX15 I 222-33-4567 OTHERPERSONTWOLAST20 FIRSTNAMEXXXX15 I 333-45-6789


123456. 123456. 123456.

123456. 123456. 123456.

123456. 123456. 123456.

123456. 123456. 123456.

123456. 123456. 123456.

123456. 123456. 123456.

123456. 123456. 123456.

123456. 123456. 123456.

123456. 123456. 123456.

123456. 123456. 123456.

123456. 123456. 123456.

123456. 123456. 123456.

SOURCE OF OTHER INCOME 123456. 123456. 123456.

123456. 123456. 123456.

123456. 123456. 123456.

SUPPORTPAIDTONAME20X 987-65-4321 123456. 123456. 123456.

123456. 123456. 123456.

123456. 123456. 123456.

123456. 123456. 123456.

123456. 123456. 123456.

123456. 123456. 123456.

123456. 123456. 123456.

123456. 123456. 123456.

123456.

123456. 123456. 123456. 123456. 10000.

123456. 123456.

[Page 24]

IN-151 Page

24

IN-151 Page

24

5432

DRAFT 21 NOV 2012

Use this worksheet to determine if you may owe tax.

An extension only allows additional time to file the Vermont income tax return and avoids a late filing penalty. If tax is due, interest and late payment penalty accrue from the original due date of the return to the date of payment.

1. Estimated individual income tax liability. . . . . . . . . . . . . . . . . . . . 1. (year)2. Previous payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.

3. Amount of tax paid with this application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.

Vermont Department of TaxesPO Box 1779Montpelier, VT 05601-1779(866) 828-2865 or (802) 828-2865

VERMONT Form IN-151Application for Extension of Time to FileForm IN-111 VT Individual Income Tax Return

CompletethisapplicationifyouareunabletofileyourVermontIncomeTaxReturn before the due date of






Irequestanautomaticsix-monthextensionoftimetoOctober15,tofilemyVermontIncomeTaxReturn.

NOTE: An extension of time to file the VT individual income tax return does NOT apply to Homestead Declaration and Property Tax Adjustment Claim (Form HS-122), or Renter Rebate Claim (Form PR-141). These forms must be filed by their specific due dates.

Rev. 10/12 Form IN-151

TAX CALCULATION WORKSHEET

PAYMENT OPTIONS

Filing by paper: Make checks payable to Vermont Department of Taxes and mail with this form to the address above.

On-line payment: Go to VTPay on our website at http://tax.vermont.gov to pay by credit card and select the “Estimated Payment” option. (There is a convenience fee for payments over $200.)

2012 123456789.

123456789.

123456789.

TY 2012





LASTNAMEXXXXXXXXXXXX FIRSTNAMEXXXXXXXXXXX I 000-11-2233 SPLASTNAMEXXXXXXXXXX SPFIRSTNAMEXXXXXXXXX I 000-22-3345 MAILING ADDRESS UP TO 35 CHARACTX35 CITYORTOWN TO TWENTY FIVE VT 05111-2241

2013 2012X

2012

APRIL 15, 2013 2012

*121513199** 1 2 1 5 1 3 1 9 9 *

[Page 25]

IN-152 Page

25

IN-152 Page

25

5432

DRAFT 21 NOV 2012

CALCULATIONS

Worksheet IN-152

Vendor version

Taxpayer’s Social Security Number Spouse or CU Partner Social Security Number

Taxpayer’s Last Name First Name Initial

Spouse or CU Partner Last Name First Name Initial

1. 90% OF 2012 VERMONT TAX MINUS CREDITS: (Form IN-111, Line 26 minus the sum of Lines 31c, 31d, and 31g multiplied by 90%) . . . . . . . . . . . . . 1.

2. 100% of 2011 VERMONT TAX MINUS CREDITS: (Form IN-111, Line 26 minus the sum of Lines 31c, 31d, and 31g) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.

3. Enter the lesser of Line 1 or Line 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.

DUE DATES OF QUARTERLY PAYMENTSCALCULATION OF UNDERPAYMENT

4. Tax payments required per quarter (Multiply Line 3 by .25) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________________________________________________

5a. From 2012 Form IN-111, add Lines 31a, 31e, and 31f, then multiply by .25 per quarter . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________________________________________________

5b. Enter 2011 overpayment and quarterly estimated payments made by the due date per quarter . . . . . . . . . . . . . . . . . ________________________________________________________________

5c. Add Lines 5a and 5b . Each quarter should not equal more than Line 4, apply any excess to the next quarter . . . . . . . . ________________________________________________________________

6. Underpayment per quarter (Subtract Line 5c from Line 4) . This line cannot be less than zero . . . . . . . . . . . . . . . . . . . . . . . . .

. 0 0

April 15, 2012 June 15, 2012 Sept. 15, 2012 Jan. 15, 2013

2012VERMONT

Underpayment of 2012 Estimated Individual Income Tax

WORKSHEET

IN-152

- - - -

, , . 0 0, ,

TAXPAYER INFORMATION

REQUIRED ANNUAL PAYMENT

. 0 0, ,

ATTACH WORKSHEETS FOR PAYMENT AMOUNTS AND DATES OF PAYMENT

ATTACH WORKSHEET SHOWING CALCULATION OF INTEREST Interest rate for 2012 is 4.8% Interest rate for 2013 is 5.6%

7. Total underpayment interest due (From attached worksheet) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7.

ATTACH WORKSHEET SHOWING CALCULATION OF PENALTY(at the rate of 1% per month or any portion thereof)

8. Total underpayment penalty due (From attached worksheet) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8.

TOTAL INTEREST AND PENALTY

9. Add Lines 7 & 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9.

. 0 0

. 0 0

. 0 0

, ,

, ,

, ,

[Page 26]

IN-152 Page

26

IN-152 Page

26

5432

DRAFT 21 NOV 2012

Worksheet IN-152A

CALCULATIONS

REQUIRED ANNUAL PAYMENT

TAXPAYER INFORMATION

Vendor version




1. 90% of 2012 VERMONT TAX MINUS CREDITS: (IN-111, Line 26 minus the sum of Lines 31c, 31d, and 31g multiplied by 90%) . . . . . . . . . . . . . . . . . . 1.2. 100% of 2011 VERMONT TAX MINUS CREDITS: (IN-111, Line 26 minus Lines 31c, 31d, and 31g) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.


4. Enter the amount from Federal Form 2210, Page 1, Line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.

Attach a copy of your Federal

Form 2210, pages 1-4

2012VERMONT

Annualized Income Installment Method for Underpayment of 2012 Estimated Individual Income Tax

WORKSHEET

IN-152A

DUE DATES OF QUARTERLY PAYMENTSCALCULATION OF UNDERPAYMENT5. Tax payments required per quarter from

Federal Form 2210, Page 4, Line 25 . . . . . . . . . . . . . . . . . . . . . ________________________________________________________________6. Vermont payment due . (Divide Line 5 by Line 4,

then multiply by Line 3 .) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________________________________________________7a. From 2012 Form IN-111, add Lines 31a, 31e, and 31f,

then multiply by .25 per quarter . . . . . . . . . . . . . . . . . . . . . . . . . ________________________________________________________________7b. Enter 2011 overpayment and quarterly estimated

payments made by the due date per quarter . . . . . . . . . . . . . . . . ________________________________________________________________7c. Add Lines 7a and 7b . Each quarter should not equal

more than Line 6, apply any excess to the next quarter . . . . . . . ________________________________________________________________8. Underpayment per quarter (Subtract Line 7c from

Line 6) . This line cannot be less than zero . . . . . . . . . . . . . . . . .

April 15, 2012 June 15, 2012 Sept. 15, 2012 Jan. 15, 2013

- - - -

. 0 0, , . 0 0, , . 0 0, , . 0 0, ,

ATTACH WORKSHEETS FOR PAYMENT AMOUNTS AND DATES OF PAYMENTATTACH WORKSHEET SHOWING CALCULATION OF INTEREST

Interest rate for 2012 is 4.8% Interest rate for 2013 is 5.6%

9. Total underpayment interest due (From attached worksheet) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9.

ATTACH WORKSHEET SHOWING CALCULATION OF PENALTY(at the rate of 1% per month or any portion thereof)

10. Total underpayment penalty due (From attached worksheet) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.

TOTAL INTEREST AND PENALTY

11. Add Lines 9 & 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.

. 0 0

. 0 0

. 0 0

, ,

, ,

, ,

[Page 27]

IN-152 Page

27

IN-152 Page

27

5432

DRAFT 21 NOV 2012 Department version

TAXP

AYER

INFO

RMAT

ION

Please Print or TypeTaxpayer’s Social Security Number Spouse or CU Partner Social Security Number



1. 90% OF 2012 VERMONT TAX MINUS CREDITS: (Form IN-111, Line 26 minus the sum of Lines 31c, 31d, and 31g multiplied by 90%) . . . . . . . . . . . . . 1.

2. 100% of 2011 VERMONT TAX MINUS CREDITS: (Form IN-111, Line 26 minus the sum of Lines 31c, 31d, and 31g) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.


REQU

IRED

ANN

UAL

PAYM

ENT

DUE DATES OF QUARTERLY PAYMENTS

CALC

ULAT

IONS

CALCULATION OF UNDERPAYMENT

4. Tax payments required per quarter (Multiply Line 3 by .25) . . . . . . . . . . . . . . . . . . . . . . . . . . . ______________________________________________________

5a. From 2012 Form IN-111, add Lines 31a, 31e, and 31f, then multiply by .25 per quarter . . . . . . . . . . . . . . . . . . . . . ______________________________________________________

5b. Enter 2011 overpayment and quarterly estimated payments made by the due date per quarter . . . . . . . . . . . . ______________________________________________________

5c. Add Lines 5a and 5b . Each quarter should not equal more than Line 4, apply any excess to the next quarter . . . ______________________________________________________

6. Underpayment per quarter (Subtract Line 5c from Line 4) . This line cannot be less than zero . . . . . . . . . . . . . . . . . . . . ______________________________________________________

7. Date FULL payment was made or April 15, 2013, whichever date is earlier . . . . . . . . . . . . . . . . . . . . . . . . . . .

CALCULATION OF INTEREST8a. Number of days AFTER the due date to the date reported

on Line 7 for each quarter, or Jan . 1, 2013, whichever date is earlier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ______________________________________________________

8b. Number of days FROM Jan . 1, 2013 to the date payment was made on Line 7 for each quarter, or April 15, 2013, whichever date is earlier . 4th quarter: Use number of days from Jan . 15, 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . ______________________________________________________

9a. Interest due for 2012 (Divide Line 8a by 365, multiply by 4 .8%, then multiply by Line 6) . . . . . . . . . . . . . . . . . . . ______________________________________________________

9b. Interest due for 2013 (Divide Line 8b by 365, multiply by 5 .6%, then multiply by Line 6) . . . . . . . . . . . . . . . . . . . ______________________________________________________

10. Interest due per quarter (Add Lines 9a and 9b) . . . . . . . . . 11. Total underpayment interest due (Add Line 10 columns) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11.CALCULATION OF PENALTY12. Number of months FROM the due date of that quarter to

the date shown on Line 7 (a portion of a month counts as a whole month) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ______________________________________________________

13. Penalty due per quarter (Multiply Line 12 by .01 (1%) then by Line 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14. Total underpayment penalty due (Add Line 13 columns) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14.

TOTAL INTEREST AND PENALTY15. Total underestimated interest and penalty due (Add Line 11 total and Line 14 total) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15.

. 0 0

. 0 0 . 0 0

TotalsApril 15, 2012 June 15, 2012 Sept. 15, 2012 Jan. 15, 2013

Worksheet IN-152

2012VERMONT

Underpayment of 2012 Estimated Individual Income Tax

WORKSHEET

IN-152

- - - -

, ,, ,, ,

[Page 28]

IN-152 Page

28

IN-152 Page

28

5432

DRAFT 21 NOV 2012 Department version

TAXP

AYER

INFO

RMAT

ION

Please Print or Type




1. 90% of 2012 VERMONT TAX MINUS CREDITS: (IN-111, Line 26 minus the sum of Lines 31c, 31d, and 31g multiplied by 90%) . . . . . . . . . . . . . . . . . . 1.2. 100% of 2011 VERMONT TAX MINUS CREDITS: (IN-111, Line 26 minus Lines 31c, 31d, and 31g) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.


4. Enter the amount from Federal Form 2210, Page 1, Line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.REQU

IRED

ANN

UAL

PAYM

ENT

Worksheet IN-152A

Attach a copy of your Federal

Form 2210, pages 1-4

2012VERMONT

Annualized Income Installment Method for Underpayment of 2012 Estimated Individual Income Tax

WORKSHEET

IN-152A

DUE DATES OF QUARTERLY PAYMENTS

CALC

ULAT

IONS

CALCULATION OF UNDERPAYMENT5. Tax payments required per quarter from

Federal Form 2210, Page 4, Line 25 . . . . . . . . . . . . . . . . ______________________________________________________6. Vermont payment due . (Divide Line 5 by Line 4,

then multiply by Line 3 .) . . . . . . . . . . . . . . . . . . . . . . . . . ______________________________________________________7a. From 2012 Form IN-111, add Lines 31a, 31e, and 31f,

then multiply by .25 per quarter . . . . . . . . . . . . . . . . . . . . ______________________________________________________7b. Enter 2011 overpayment and quarterly estimated

payments made by the due date per quarter . . . . . . . . . . . ______________________________________________________7c. Add Lines 7a and 7b . Each quarter should not equal

more than Line 6, apply any excess to the next quarter . . ______________________________________________________8. Underpayment per quarter (Subtract Line 7c from

Line 6) . This line cannot be less than zero . . . . . . . . . . . . ______________________________________________________9. Date FULL payment was made or April 15, 2013,

whichever date is earlier . . . . . . . . . . . . . . . . . . . . . . . . . .CALCULATION OF INTEREST10a. Number of days AFTER the due date to the date reported

on Line 9 for each quarter, or Jan . 1, 2013, whichever date is earlier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ______________________________________________________

10b. Number of days FROM Jan . 1, 2013 to the date payment was made on Line 9 for each quarter, or April 15, 2013, whichever date is earlier . 4th quarter: Use number of days from Jan . 15, 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . ______________________________________________________

11a. Interest due for 2012 (Divide Line 10a by 365, multiply by 4 .8%, then multiply by Line 8) . . . . . . . . . . . . . . . . . . ______________________________________________________

11b. Interest due for 2013 (Divide Line 10b by 365, multiply by 5 .6%, then multiply by Line 8) . . . . . . . . . . . . . . . . . . ______________________________________________________

12. Interest due per quarter (Add Lines 11a and 11b) . . . . . .13. Total underpayment interest due (Add Line 12 columns) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13.CALCULATION OF PENALTY14. Number of months FROM the due date of that quarter to

the date shown on Line 9 (a portion of a month counts as a whole month) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ______________________________________________________

15. Penalty due per quarter (Multiply Line 14 by .01 (1%) then by Line 8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ______________________________________________________

16. Total underpayment penalty due (Add Line 15 columns) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16.

TOTAL INTEREST AND PENALTY17. Total underestimated interest and penalty due (Add Line 13 total and Line 16 total) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17.

TotalsApril 15, 2012 June 15, 2012 Sept. 15, 2012 Jan. 15, 2013

- - - -

. 0 0, , . 0 0, , . 0 0, , . 0 0, ,

[Page 29]

IN-153 Page

29

IN-153 Page

29

5432

DRAFT 21 NOV 2012


Schedule IN-153

2012 Capital Gain Exclusion Calculation Schedule IN-153 ATTACH TO FORM IN-111


SSN 000112233

1 123456789

2a 123456789

2b 123456789

3 123456789

4 123456789

5a 123456789

5b 123456789

5c 123456789

5d 123456789

5e 123456789

6 123456789

7 123456789

8 123456789

9 123456789

10 123456789

11 123456789

12 123456789

13a -123456789

13b -123456789

13c -123456789

14 -123456789

15 123456789

16 123456789

17 123456789

18 123456789

19 123456789

20 123456789

21 123456789


*121533199** 1 2 1 5 3 3 1 9 9 *

[Page 30]

IN-153 Page

30

IN-153 Page

30

5432

DRAFT 21 NOV 20122012 Schedule IN-153, Page 2 This page must be filed with Page 1 of this schedule.Last Name Your Social Security Number

Schedule IN-153


PART I Flat Exclusion 1. Enter smaller of Line 15 or 16 from Federal Form 1040, Schedule D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. 2. Enter amount from: 2a. Federal Form 1040, Schedule D, Line 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a. 2b. Federal Form 1040, Schedule D, Line 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2b. 3. Add Lines 2a and 2b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. 4. Subtract Line 3 from Line 1.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.If you filed Federal Form 4952, complete Lines 5 through 7 5. Enter amount from: 5a. Federal Form 4952, Line 4g . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5a. 5b. Federal Form 4952, Line 4e. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5b. 5c. Multiply Line 5a by Line 5b and enter result here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5c. 5d. Federal Form 4952, Line 4b. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5d. 5e. Federal Form 4952, Line 4e. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5e. 6. Add Lines 5d and 5e; enter result here.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. 7. Divide Line 5c by Line 6; enter result here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. 8. Subtract Line 7 from Line 4. Entry cannot be less than zero. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 9. Enter the smaller of Line 8 or $5,000. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.

PART II Percentage Exclusion (Use this section only if you have eligible gains. See Technical Bulletin 60 for more information.) 10. Enter the amount from Part I, Line 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10. 11. Enter amount of adjusted net capital gain from the sale of assets held for three years or less. . . . 11. 12. Assets held for more than three years. Subtract Line 11 from Line 10. Entry cannot be less than zero. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.Enter the amount of net adjusted capital gain from the sale of the following assets held for more than three years 13a. Real estate or portion of real estate used as a primary or nonprimary home . . . . . . . . . . . . 13a. 13b. Depreciable personal property (except for farm property or standing timber) . . . . . . . . . 13b. 13c. Stocks or bonds publicly traded or traded on an exchange or any other financialinstruments(Seeinstructionsforinformationonanegative.) . . . . . . . . . . . . . . . . . 13c. 14. Add Lines 13a through 13c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14. 15. Subtract Line 14 from Line 12; enter result here. This is the amount of net adjusted capital gain eligible for exclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.Line 16 Federal Form 4952 information. If no investment interest expense for ineligible assets reported on Federal Form 4952, enter Line 7 from Part I of this form. Otherwise, you mayneedtorecomputeFederalForm4952toreflectonlyinvestmentinterestincomeforassetseligibleforthecapitalgainexclusion. 16. Enter amount from Part I, Line 7 or recomputed Federal Form 4952. . . . . . . . . . . . . . . . . . . . . . . . 16. 17. Subtract Line 16 from Line 15.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17. 18. Multiply Line 17 by 40%; enter result here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.

PART III Capital Gain Exclusion 19. Enter the greater of Line 9 or Line 18. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. Multiply ______________________________________ x 40%; enter result here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20. (Federal Taxable Income from IN-111, Line 11) 21. Enter the smaller of Line 19 or Line 20. This is your capital gain exclusion. Enter on Form IN-111, Line 14b. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.


123456789. 123456789.

123456789.

-123456789. -123456789.

-123456789. -123456789.

123456789.

123456789. 123456789. 123456789.

123456789.

123456789. 123456789. 123456789. 123456789.

123456789. 123456789. 123456789. 123456789. 123456789. 123456789. 123456789. 123456789. 123456789.

123456789. 123456789. 123456789.

123456789.

[Page 31]

IN-154 Page

31

IN-154 Page

31

5432

DRAFT 21 NOV 20122012 State/Local Income Tax Addback Schedule IN-154

Schedule IN-154


PART A 2012 Federal Form 1040, Schedule A Deduction 1. Enter amount of itemized deductions from Federal Form 1040, Schedule A, Line 29. . . . . . . . . . . . . . . . . . . . . . 1. 2. Enterallowablefederalstandarddeductionforyourfilingstatus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.

3. Subtract Line 2 from Line 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. 4. Enter amount of state and local income taxes from Federal Form 1040, Schedule A, Line 5 . . . . . . . . . . . . . . . . 4. 5. Allowable state and local income taxes deduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. 6. Subtract Line 5 from Line 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.

PART B Adjustment for Recapture of Excess 2011 Addback 7. Enter amount from your 2012 Federal Form 1040, Line 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. If entry is zero, skip Parts B & C and enter Line 6 on Form IN-111, Line 12c. 8. Enter amount from 2011 VT Schedule IN-154, Line 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 9. Enter the lesser of Line 7 or Line 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.

PART C Adjusted 2012 Addback 10. Subtract Line 9 from the lesser of Line 3 or Line 6. This is the 2012 addback amount. . . . . . . . . . . . . . . . . . . . 10. If the difference is less than zero, indicate a negative number.

Enter this amount on Form IN-111, Line 12c. If the difference is less than zero, indicate a negative number on Form IN-111, Line 12c.


You must complete this schedule if you filed Federal Form 1040, Schedule Aand your State and Local Income Taxes deduction for 2012 tax year on FederalForm 1040, Schedule A, Line 5 exceeds $5,000. ATTACH TO FORM IN-111

StandardSingle 5,950Married Filing Jointly or Qualifying Widow(er) 11,900Married Filing Separately 5,950Head of Household 8,700

For those born before January 1, 1948 or blind and entry on Federal Form 1040, Line 39a is

1 2 3 4 7,400 8,850 n/a n/a 13,050 14,200 15,350 16,500 7,100 8,250 9,400 10,550 10,150 11,600 n/a n/a

OR

SSN 000112233

1 123456789

2 16500

3 123456789

4 123456789

5 5000

123456789. 16200.

123456789. 123456789. 5000. 123456789.

123456789.

123456789. 123456789.

-123456789.

6 123456789

7 123456789

8 123456789

9 123456789

10 -123456789


*121543199** 1 2 1 5 4 3 1 9 9 *

[Page 32]

RW-171 Page

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RW-171 Page

32

DRAFT 21 NOV 2012

VERMONT WITHHOLDING TAX RETURNFOR TRANSFER OF REAL PROPERTY

TO BE COMPLETED BY THE BUYER OR OTHER TRANSFEREE REQUIRED TO WITHHOLDFILE THIS RETURN AND ALL SCHEDULE “A”s WITH THE

VERMONT DEPARTMENT OF TAXES, 133 STATE STREET, MONTPELIER, VERMONT 05633

PLEASE TYPE OR PRINT CLEARLY. USE BLUE OR BLACK INK ONLY.

3. ADDRESS (NUMBER AND STREET)

4. CITY, STATE, AND ZIP CODE

6. SOCIAL SECURITY NUMBER / FEDERAL I.D. NUMBER

7. ADDRESS (NUMBER AND STREET)

8. CITY, STATE, AND ZIP CODE

9. LOCATION AND DESCRIPTION OF PROPERTY 10. DATE PROPERTY ACQUIRED BY SELLER

15. NUMBER OF SCHEDULE “A”s FILLED OUT FOR THIS PROPERTY TRANSFER

I hereby certify that this return and attached Schedule “A”s are true, correct and complete to the best of my knowledge. If prepared by a person other than the taxpayer, this declaration further provides that under 32 V.S.A. §5901 this information has not been and will not be used for any other purpose or made available to any person other than for the preparation of this return unless a separate valid consent form is signed by the taxpayer and retained by the preparer.

Form RW-171(Rev. 11/08)

Keep a copy of this return for your records.

PLEASE REMEMBER TO ATTACH ALL SCHEDULE “A”s FROM LINE 15 TO THIS FORM FOR PROPER REW CREDIT. FORM WILL BE RETURNED WITHOUT PROPER NUMBER OF SCHEDULE “A”s AND/OR IF SCHEDULE “A”s ARE INCOMPLETE.

Signature of buyer Date Daytime Telephone Number




1. NAME OF WITHHOLDING AGENT (BUYER OR OTHER TRANSFEREE) 2. SOCIAL SECURITY NUMBER / FEDERAL I.D. NUMBER

5. NAME OF WITHHOLDING AGENT (BUYER OR OTHER TRANSFEREE)

11. DATE OF TRANSFER 12. TOTAL CONSIDERATION PAID 13. RATE OF WITHHOLDING 14. AMOUNT WITHHELD(A) 2.5% OF SALES PRICE(B) LESS THAN 2.5%. Attach withholding certificate and enter certificate number

MAKE CHECK PAYABLE TO: VERMONT DEPARTMENT OF TAXES

PAGE 1

BUYERS: PLEASE COMPLETE AND ATTACH SCHEDULE “A”s FOR

PROPER REW CREDIT

(A Schedule A is required for each individual or entity receiving proceeds from the transfer.)

Signature of preparer if other than taxpayer Date Telephone Number

Address of preparer

5432

[Page 33]

RW-171 Page

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RW-171 Page

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5432

DRAFT 21 NOV 2012REW - SCHEDULE A Form RW-171FILE ORIGINAL ONLY. DO NOT COPY. ATTACH TO RW-171, PAGE 1.PLEASE TYPE OR PRINT CLEARLY. USE BLUE OR BLACK INK ONLY.

TO BE COMPLETED BY THE BUYER OR OTHER TRANSFEREE REQUIRED TO WITHHOLD

1. Check box to indicate whether SELLER is: Individual(s)* C-Corporation** Composite Business Entity** *Partnerships, S-Corporations, Trusts & LLC’s check “Individual(s)” and complete a Schedule A for each individual receiving proceeds from the sale. **C-Corporation and Composite Business Entity please see Line 1 instructions.

2. Taxpayer’s Social Security Number Spouse’s Social Security Number 3. Federal ID number of seller (if applicable)

4. Taxpayer’s Last Name First Name Initial

Spouse’s Last Name First Name Initial

C-Corporation Name or Composite Business Entity Name (if checked above)

5. Mailing Address (Number and Street or Road Name)

6. City or Town State Zip Code Check if this is an INTERNATIONAL address7. Location and description of property

8. Date property acquired by seller 9. Date of transfer 10. Total consideration

11. Percentage of total gross proceeds received by this seller 12. Amount withheld for this seller %

Pass-through information. If the individual above is a shareholder, partner or member of an S-corporation, Partnership or Limited Liability Com-pany and sold the real property, please identify the business. Do not complete Lines 13 & 14 if composite entity is checked on Line 1.

13. Name of Business 14. Federal ID Number


Form RW-171(Rev. 11/08)PAGE 2

DO NOT COPY. For additional Schedule “A”s, call (802) 828-2515.

X X X

000-11-2233 000-22-3345 321564987

LASTNAMEXXXXXXXXXXXX FIRSTNAMEXXXXXXXXXXX I SPLASTNAMEXXXXXXXXXX SPFIRSTNAMEXXXXXXXXX I

C CORPORATION NAME UP TO 35 CHARA35

MAILING ADDRESS UP TO 35 CHARACTX35 CITYORTOWN TO TWENTY FIVE VT 05111-2241 X LOCATION AND DESCRIPTION OF PROPX35

11/30/1986 12/20/2001 12345678.90

100.00 1234567.89

NAME OF BUSINESS UP TO 35 CHARACTER 12456789



C CORPORATION NAME UP TO 35 CHARA35 321564987



L7 LOCATION AND DESCRIPTION OF PROPX35 L8 11301986

L9 12202001 L10 1234567890 L11 10000 L12 123456789

*081713299** 0 8 1 7 1 3 2 9 9 *

[Page 34]

IN-111 Page

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IN-111 Page

34

ID #

DRAFT 21 NOV 2012Staple W-2/1099’s here 2012 VT INCOME TAX RETURN DUE DATE: April 15, 2013


Form IN-111


Your signature Date Occupation Preparer’s signature Date Print Firm’s name (or yours if self-employed) and address below Spouse or CU Partner signature. If a joint return, BOTH must sign. Date Occupation Taxpayer’s Telephone Number Spouse or CU Partner Telephone Number Preparer’s Telephone #

1. VT School Code 2. 911 street address on 12/31/2012

Your SSN


9. Exemptions Claimed

Taxpayer’s NameSpouse/CU Partner NameMailing AddressCity, State, ZIP

5 64321 8 9 10

12 14 18 20

25

2726

7

11 13 17

28 29

32

37

39

30

33 35

41

31

34

40

36

38

42 43

44 45

46 47

48 49

50 51

52 53

54 55

56 57

60 61

62 63

64 65

76

66 67

68 69

70 71

72 73

74 75

77

92 93

94 95

96 97

98 99

100 101

102 103

104 105

78 79

80 81

84 85

86 87

88 89

90 91

108 109

110 111

112 113

114 115

116 117

118 119

120 121

122 123

124 125

126 127

128 129 130 131

22 23 24

2119

58 59 106 10782 83

1615

*121113199** 1 2 1 1 1 3 1 9 9 *

[Page 35]

IN-111 Page

35

IN-111 Page

35

DRAFT 21 NOV 20122012 IN-111, Page 1 Specifications

• Use COURIER 12 POINT FONT for all printing in the scanband area .• DATA must be present IN ALL FIELDS unless otherwise specified. (See page 6)• DO NOT allow MORE characters in the taxpayer-readable portion than is allowed by “Field Length” . (See page 6)• DO NOT USE PUNCTUATION or symbols in the scanband . (See page 6)• Use ALL CAPITAL LETTERS for variable data alpha characters . (See page 6)• Round dollars to the nearest whole dollar . Default to zero (“0”) . Do not show cents in the scanband area . (See page 6)• Percentages are shown with an implied decimal point and two places to the right of the implied decimal point . (See

page 7)• Barcode begins at grid 58/4 and ends at grid 80/6.• Numbers beneath the barcode begin at grid 59/7 and end at grid 79/7. There is a space between each character. Use

Courier 12 point font .

Field Starts FieldID # in grid Length Field Type, Title, Explanation and Requirements

1 7/17 2 This is an alpha field. Department ID Code. Must be “TY” .2 12/17 4 This is a numeric field. This is the Tax Year. Must be “2012” .3 21/17 3 This is an alpha field. Department ID Code. Must be “REC” .4 27/17 1 This is an alpha field. This is the answer to “Are you using RECOMPUTED Federal Return

Information?” . Must be “Y” or N” .5 33/17 3 This is an alpha field. Department ID Code. Must be “AMD” .6 39/17 1 This is an alpha field. This is the answer to “Is this an amended 2012 return?”. Must be “Y”

or N” .7 45/17 3 This is an alpha field. Department ID Code. Must be “TDC” .8 51/17 1 This is an alpha field. This is the answer to “Did Taxpayer die during 2012?”. Must be “Y”

or “N” .9 57/17 3 This is an alpha field. Department ID Code. Must be “SDC” .10 63/17 1 This is an alpha field. This is the answer to “Did Spouse/CU Partner die during 2012?”. Must

be “Y” or “N” .11 7/19 3 This is an alpha field. Department ID Code. Must be “DSC” .12 13/19 1 This is an alpha field. This is the answer to “Do you authorize the VT Department of Taxes to

discuss this return with your preparer?” . Must be “Y” or “N” .13 19/19 3 This is an alpha/numeric field. Department ID Code. Must be “T65” .14 25/19 1 This is an alpha field. This is the answer to “Is Taxpayer age 65 or older as of December 31,

2012?” . Must be “Y” or “N” .15 31/19 3 This is an alpha/numeric field. Department ID Code. Must be “S65” .16 37/19 1 This is an alpha field. This is the answer to “Is Spouse/CU Partner age 65 or older as of

December 31, 2012?” . Must be “Y” or “N” .17 43/19 2 This is an alpha field. Department ID Code. Must be “FS” .18 48/19 1 This is an alpha field. This is the filing status. Must be “S” for Single; “H” for Head of

Household; “J” for Married Filing Jointly; “P” for Married Filing Separately; “U” for Civil Union Filing Jointly; “C” for Civil Union Filing Separately; or “Q” for Qualifying Widow(er) . IF filing separately (“P” or “C”), DO NOT put Spouse or CU Partner’s name on Page 1 of the return. Put their name on the specified line on IN-111, Page 2 ONLY.

19 52/19 9 This is a numeric field. This is the Spouse or CU Partner Social Security Number only IF FILING SEPARATELY (“P” or “C”). Must be 9 digits; or, if NOT filing separately, leave this field blank.

20 66/19 2 This is an alpha field. Department ID Code. Must be “EX” .21 71/19 2 This is a numeric field. This is the number of Exemptions Claimed (Line 9). 22 7/21 20 This is an alpha field. Taxpayer’s Last Name. This is a REQUIRED ENTRY .23 31/21 20 This is an alpha field. Taxpayer’s First Name. This is a REQUIRED ENTRY .24 54/21 1 This is an alpha field. Taxpayer’s Middle Initial.

[Page 36]

IN-111 Page

36

IN-111 Page

36

DRAFT 21 NOV 201225 59/21 9 This is a numeric field. Taxpayer’s Social Security Number. Must be 9 digits. This is a

REQUIRED ENTRY .26 7/23 20 This is an alpha field. Spouse or CU Partner Last Name. If there is no Spouse or CU Partner,

OR if filing status is “P” or “C”, leave this field blank.27 31/23 20 This is an alpha field. Spouse or CU Partner First Name. If there is no Spouse or CU Partner,

OR if filing status is “P” or “C”, leave this field blank.28 54/23 1 This is an alpha field. Spouse or CU Partner Middle Initial. If there is no Spouse or CU

Partner, OR if filing status is “P” or “C”, leave this field blank.29 59/23 9 This is a numeric field. Spouse or CU Partner Social Security Number IF FILING JOINTLY.

Must be 9 digits; or, if there is no Spouse or CU Partner, leave this field blank. If filing status is “P” or “C”, enter Spouse or CU Partner Social Security Number in Field #19 and on Page 2 only.

30 7/25 35 This is an alpha/numeric field. Mailing Address. 31 47/25 25 This is an alpha field. City or Town for mailing address. 32 77/25 2 This is an alpha field. State for mailing address. Use the standard 2-character state abbreviation.33 7/27 9 This is a numeric field. ZIP Code for mailing address. Must have 5 or 9 digits only. DO NOT

enter a hyphen (-) or space between the 5-digit ZIP Code and the “+4” digits.34 28/27 3 This is a numeric field. This is the VT School Code for Legal Residence as of December 31, 2012.

MUST be 3 digits . Example: “003”, not “3” . Must be “001” - “262” for residents or “999” for nonresidents . This may identify a different city/town than that used for mailing address. This is a REQUIRED ENTRY .

35 37/27 25 This is an alpha/numeric field. This is the 911 street address . This is a REQUIRED ENTRY . This may be different than the mailing address.

36 7/29 2 This is a numeric field. Department ID Code. Must be “10” .37 13/29 10 This is a dollar amount field. This is the Adjusted Gross Income (Line 10). Use the amount

from Federal Form 1040, Line 37; 1040A, Line 21; or 1040EZ, Line 4. Put a hyphen (-) at the beginning of the amount to indicate a loss .

38 7/31 2 This is a numeric field. Department ID Code. Must be “11” .39 13/31 10 This is a dollar amount field. This is the Federal Taxable Income (Line 11). Use the amount

from Federal Form 1040, Line 43; 1040A, Line 27; or 1040EZ, Line 6. If the Federal amount is zero, and you have non-VT state and local obligations: From Federal Form 1040, subtract Line 42 from Line 41. From Federal Form 1040A, subtract Line 26 from Line 25. Put a hyphen (-) at the beginning of the amount to indicate a loss .

40 7/33 3 This is an alpha/numeric field. Department ID Code. Must be “12a” .41 14/33 9 This is a dollar amount field. This is the Income from Non-VT State and Local Obligations

(Line 12a) . Use the amount from Schedule IN-112, Part I, Line 3 (Schedule IN-112, Field #8).

42 7/35 3 This is an alpha/numeric field. Department ID Code. Must be “12b” .43 14/35 9 This is a dollar amount field. This is Bonus Depreciation allowed under Federal law for 2012

(Line 12b) .44 7/37 3 This is an alpha/numeric field. Department ID Code. Must be “12c” .45 13/37 10 This is a dollar amount field. This is Addback of State and Local Income Taxes (Line 12c).

Use the amount from Schedule IN-154, Line 10 (Schedule IN-154, Field #22). Put a hyphen (-) at the beginning of the amount to indicate a negative number .

46 7/39 2 This is a numeric field. Department ID Code. Must be “13” .47 13/39 10 This is a dollar amount field. This is the Federal Taxable Income with Additions (Line 13).

Add Lines 11, 12a, 12b, and 12c (Fields #39, #41, #43, and #45) . Put a hyphen (-) at the beginning of the amount to indicate a loss .

48 7/41 3 This is an alpha/numeric field. Department ID Code. Must be “14a” .49 14/41 9 This is a dollar amount field. This is the Interest Income from U.S. Obligations (Line 14a). 50 7/43 3 This is an alpha/numeric field. Department ID Code. Must be “14b” .51 14/43 9 This is a dollar amount field. This is the Capital Gains Exclusion (Line 14b). Use the amount

from Schedule IN-153, Line 21 (Schedule IN-153, Field #58).52 7/45 3 This is an alpha/numeric field. Department ID Code. Must be “14c” .

[Page 37]

IN-111 Page

37

IN-111 Page

37

DRAFT 21 NOV 201253 14/45 9 This is a dollar amount field. This is the Adjustment for prior years’ Bonus Depreciation (Line

14c) .54 7/47 3 This is an alpha/numeric field. Department ID Code. Must be “14d” .55 14/47 9 This is a dollar amount field. This is the amount from Line 14d. Add Lines 14a, 14b, and

14c (Fields #49, #51, and #53) .56 7/49 2 This is a numeric field. Department ID Code. Must be “15” .57 14/49 9 This is a dollar amount field. This is the VT Taxable Income (Line 15). Subtract Line 14d

from Line 13. If negative, enter “0”.58 7/51 2 This is a numeric field. Department ID Code. Must be “16” .59 14/51 9 This is a dollar amount field. This is the VT Income Tax from VT Tax Table or Tax Rate

Schedule on Line 15 amount (Line 16) . 60 28/29 2 This is a numeric field. Department ID Code. Must be “17” .61 33/29 9 This is a dollar amount field. This is the Additions to VT Income Tax (Line 17). Use the

amount from Schedule IN-112, Part II, Line 7 (Schedule IN-112, Field #22). 62 28/31 2 This is a numeric field. Department ID Code. Must be “18” .63 33/31 9 This is a dollar amount field. This is the VT Income Tax with Additions (Line 18). Add Lines

16 and 17 (Fields #59 and #61).64 28/33 2 This is a numeric field. Department ID Code. Must be “19” .65 33/33 9 This is a dollar amount field. This is the Subtractions from VT Income Tax (Line 19). Use the

amount from Schedule IN-112, Part II, Line 15 (Schedule IN-112, Field #38).66 28/35 2 This is a numeric field. Department ID Code. Must be “20” .67 33/35 9 This is a dollar amount field. This is the VT Income Tax (Line 20). Subtract Line 19 (Field

#65) from Line 18 (Field #63). If negative, enter “0”. 68 28/37 2 This is a numeric field. Department ID Code. Must be “21” .69 37/37 5 This is a numeric (percentage) field. This is the Income Adjustment (Line 21). Use the figure

from Schedule IN-113, Line 43 (Schedule IN-113, Field #150). If Schedule IN-113 is not required, enter 100.00% (“10000”). Cannot be less than 0% (“0”) or more than 100% (“10000”)

70 28/39 2 This is a numeric field. Department ID Code. Must be “22” .71 33/39 9 This is a dollar amount field. This is the Adjusted VT Income Tax (Line 22). Multiply Line

20 (Field #67) by Line 21 (Field #69).72 28/41 2 This is a numeric field. Department ID Code. Must be “23” .73 33/41 9 This is a dollar amount field. This is the Credit for Income Tax Paid to Other State or Canadian

Province (Line 23) . Use the amount from Schedule IN-117, Line 21 (Schedule IN-117, Field #44). If claiming credit for more than one state or province, fill out a separate Schedule IN-117 for each state or province. Add Line 21 amount from all Schedules IN-117 and enter total here.

74 28/43 2 This is a numeric field. Department ID Code. Must be “24” .75 33/43 9 This is a dollar amount field. This is the VT Tax Credits (Line 24). Use the amount from

Schedule IN-112, Part IV, Line 7 (Schedule IN-112, Field #106) OR Schedule IN-119 (Field #64 or Field #128).

76 28/45 2 This is a numeric field. Department ID Code. Must be “25” .77 33/45 9 This is a dollar amount field. This is the Total VT Credits (Line 25). Add Lines 23 and 24

(Fields #73 and #75).78 28/47 2 This is a numeric field. Department ID Code. Must be “26” .79 33/47 9 This is a dollar amount field. This is the VT Income Tax After Credits (Line 26). Subtract

Line 25 (Field #77) from Line 22 (Field #71). If negative, enter “0”.80 28/49 2 This is a numeric field. Department ID Code. Must be “27” .81 33/49 9 This is a dollar amount field. This is the Use Tax (Line 27).82 28/51 2 This is a numeric field. Department ID Code. Must be “28” .83 33/51 9 This is a dollar amount field. This is the Total VT Taxes (Line 28). Add Lines 26 and 27

(Fields #79 and #81).84 46/29 3 This is an alpha/numeric field. Department ID Code. Must be “29a” .

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DRAFT 21 NOV 201285 56/29 4 This is a dollar amount field. This is the Voluntary Contribution to Nongame Wildlife Fund

(Line 29a) .86 46/31 3 This is an alpha/numeric field. Department ID Code. Must be “29b” .87 56/31 4 This is a dollar amount field. This is the Voluntary Contribution to Children’s Trust Fund (Line

29b) .88 46/33 3 This is an alpha/numeric field. Department ID Code. Must be “29c” .89 56/33 4 This is a dollar amount field. This is the Voluntary Contribution to VT Veterans’ Fund (Line

29c) .90 46/35 3 This is an alpha/numeric field. Department ID Code. Must be “29d” .91 55/35 5 This is a dollar amount field. This is the Total Voluntary Contributions (Line 29d). Add Lines

29a, 29b, and 29c (Fields #85, #87, and #89).92 46/37 2 This is a numeric field. Department ID Code. Must be “30” .93 51/37 9 This is a dollar amount field. This is the Total of VT Taxes & Voluntary Contributions (Line

30) . Add Lines 28 and 29d (Fields #83 and #91).94 46/39 3 This is an alpha/numeric field. Department ID Code. Must be “31a” .95 52/39 8 This is a dollar amount field. This is the VT Tax Withheld (Line 31a). Enter combined amount

of VT withholding shown on all W-2s, 1099s, etc .96 46/41 3 This is an alpha/numeric field. Department ID Code. Must be “31b” .97 52/41 8 This is a dollar amount field. This is the combined amount from Form IN-114, Estimated Tax

for 2012 and/or Form IN-151, Extension with payment (Line 31b) . 98 46/43 3 This is an alpha/numeric field. Department ID Code. Must be “31c” .99 56/43 4 This is a dollar amount field. This is the Earned Income Tax Credit (Line 31c). Use the

amount from Schedule IN-112, Part III, Line III-2 (Schedule IN-112, Field #48) or Line III-9 (Schedule IN-112, Field #68).

100 46/45 3 This is an alpha/numeric field. Department ID Code. Must be “31d” .101 55/45 5 This is a dollar amount field. This is the Renter Rebate (Line 31d). Use the amount from

Form PR-141, Line 9 (PR-141, Field #45). IMPORTANT NOTE: DO NOT allow user to manually enter an amount in this field. If

an amount other than “0” is entered on this line, Form PR-141 and Schedule HI-144 must be completed and printed from the same software and at the same time as Form IN-111 and its accompanying schedules.

102 46/47 3 This is an alpha/numeric field. Department ID Code. Must be “31e” .103 53/47 7 This is a dollar amount field. This is the amount from Form RW-171, VT Real Estate Withholding

(Line 31e) . NOTE: Form RW-171 would have been filed at the time of the real estate closing.104 46/49 3 This is an alpha/numeric field. Department ID Code. Must be “31f” .105 53/49 7 This is a dollar amount field. This is the amount from Form WH-435 Estimated Income Tax

Payment made by Business Entity for Nonresident Partner, Member, or Shareholder (Line 31f) .106 46/51 3 This is an alpha/numeric field. Department ID Code. Must be “31g” .107 55/51 5 This is a dollar amount field. This is Additional Refundable Credits (Line 31g). Use the amount

from Low Income Child & Dependent Care Worksheet, “Low Income Credit IN-111, Line 31g.” (worksheet is included in 2012 Income Tax Booklet instructions); OR, 50% of the Federal Child and Dependent Care Credit. NOTE: You cannot use both IN-111, Line 31g and IN-112, Part II, Line 8 on the same return.

108 64/29 3 This is an alpha/numeric field. Department ID Code. Must be “31h” .109 71/29 9 This is a dollar amount field. This is the Total Payments and Credits (Line 31h). Add Lines

31a (Field #95) through 31g (Field #107).110 64/31 2 This is a numeric field. Department ID Code. Must be “32” .111 71/31 9 This is a dollar amount field. This is the Overpayment (Line 32).112 64/33 3 This is an alpha/numeric field. Department ID Code. Must be “33a” .113 72/33 8 This is a dollar amount field. This is the Amount to be credited to 2013 Estimated Tax Payment

(Line 33a) . Amount on Line 31d (Field #101) CANNOT be used for 2013 estimated tax payments. [Line 33a (Field #113) CANNOT be more than Line 32 (Field #111) minus Line 31d (Field #101)].

114 64/35 3 This is an alpha/numeric field. Department ID Code. Must be “33b” .

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DRAFT 21 NOV 2012115 72/35 8 This is a dollar amount field. This is the Line 32 Amount to be credited to 2013 Property Tax

Bill (Line 33b) . Line 33a (Field #113) plus Line 33b (Field #115) CANNOT be more than Line 32 (Field #111).

116 64/37 2 This is a numeric field. Department ID Code. Must be “34” .117 71/37 9 This is a dollar amount field. This is the Refund Amount (Line 34). Subtract Lines 33a (Field

#113) and 33b (Field #115) from Line 32 (Field #111).118 64/39 2 This is a numeric field. Department ID Code. Must be “35” .119 71/39 9 This is a dollar amount field. This is the Balance Due (Line 35). 120 64/41 2 This is a numeric field. Department ID Code. Must be “36” .121 72/41 8 This is a dollar amount field. This is the Interest and Penalty on Underpayment of Estimated

Tax (Line 36) . Use the amount from Worksheet IN-152 or IN-152A.122 64/43 2 This is a numeric field. Department ID Code. Must be “37” .123 71/43 9 This is a dollar amount field. This is the Total Balance Due (Line 37). Add Lines 35 (Field

#119) and 36 (Field #121).124 64/45 4 This is an alpha field. Department ID Code. Must be “PTIN” .125 71/45 9 This is an alpha/numeric field. Preparer’s Social Security Number or PTIN. Must be 9 characters.

If this return is self-prepared, leave this field blank.126 64/47 4 This is an alpha field. Department ID Code. Must be “PEIN” .127 71/47 9 This is a numeric field. This is the Preparer’s EIN. Must be 9 digits. If this return is self-

prepared, leave this field blank.128 7/53 6 This is an alpha field. Department ID Code. Must be “REFUND” .129 16/53 9 This is a dollar amount field. This is the amount of REFUND EXPECTED AT THIS TIME.

If this is an original filing, this will be the same as Line 34 (Field #117) . If this is an AMENDED return, show the difference between the original filing and the amended filing. Examples: 1) If the original return showed a tax due of $25 and the amended return shows a refund of $35, show “60” in “REFUND” field; 2) If the original return showed a refund of $56 and the amended return shows a refund of $80, show “24” in “REFUND” field.

130 59/53 7 This is an alpha field. Department ID Code. Must be “AMT DUE” .131 69/53 9 This is a dollar amount field. This is the amount of TAX DUE AT THIS TIME. If this is an

original filing, this will be the same as Line 37 (Field #123) . If this is an AMENDED return, show the difference between the original filing and the amended filing. Examples: 1) If the original return showed a refund of $25 and the amended return shows a tax due of $15, show “40” in “TAX DUE” field; 2) If the original return showed a tax due of $100, and the amended return shows a tax due of $115, show “15” in the “TAX DUE” field.

ID # 7/63 4 This is the 4-digit Vendor ID Number which is assigned by NACTP .

NOTE: The “For amended returns only” box on Form IN-111, Page 2 is for reference purposes for calculating the additional amount owed or additional refund expected . To amend a 2012 tax return, fill out the 2012 Form IN-111 as if it were the original filing, making sure to indicate “Yes” for the question “Is this an amended return?” (“Y” in Field #6).

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ID #

DRAFT 21 NOV 2012

2012 VT Tax Adjustments and Credits

Schedule IN-112




PART I ADJUSTMENT TO TAXABLE INCOME

I-1. Total interest and dividend income from all state and local obligations exempt from federal tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-1.I-2. Interest and dividend income from VT state and local obligations included in Line I-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-2.I-3. INCOME FROM NON-VT STATE AND LOCAL OBLIGATIONS TO BE ADDED TO VT TAXABLE INCOME. Subtract Line I-2 from Line I-1, but not less than zero. ENTER ON FORM IN-111, LINE 12a. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-3.

(IN-112 Line-by-Line Information continued on Page 2)Schedule IN-112

ATTACH TO FORM IN-111

5 6

43

21

8

9 10

7

11 12

13 14

15 16

17 18

19 20

21 22

23 24

25 26

29 30

31 32

33

35

34

36

37 38

43 44

45 46

47 48

49 50

53 54

55 56

57 58

59 60

61 62

63 64

65 66

67 68

69 70

71 72

73 74

75 76

81 82

79 80

27 28

51 52

83 84

85 86

87 88

89

91

93

95

99

90

92

94

96

98

101 102

103

105

104

106

77 78

39 40

41 42

97

100

*121123199** 1 2 1 1 2 3 1 9 9 *

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41






1 7/14 3 This is an alpha field. Department ID Code. Must be “SSN” .2 14/14 9 This is a numeric field. Taxpayer’s Social Security Number (same as Form IN-111, Field

#25).

PART I (Fields #3 - #8)3 7/16 3 This is an alpha/numeric field. Department ID Code. Must be “I-1”.4 16/16 7 This is a dollar amount field. This is the amount from Part I, Line 1 (Total interest and dividend

income from all state and local obligations exempt from federal tax) .5 7/18 3 This is an alpha/numeric field. Department ID Code. Must be “I-2” .6 16/18 7 This is a dollar amount field. This is the amount from Part I, Line 2 (Interest and dividend

income from VT state and local obligations included in Line I-1) .7 7/20 3 This is an alpha/numeric field. Department ID Code. Must be “I-3” .8 16/20 7 This is a dollar amount field. This is the amount from Part I, Line 3 (Income from Non-VT

state and local obligations to be added to VT Taxable Income) . Cannot be less than zero . Enter this amount on Form IN-111, Line 12a (Form IN-111, Field #41).

PART II (Fields #9 - #38)9 7/22 4 This is an alpha/numeric field. Department ID Code. Must be “II-1” .10 16/22 7 This is a dollar amount field. This is the amount from Part II, Line 1 (Tax on Qualified Plans

including IRA, HSA, and MSA) . Use the combined amounts from Federal Form 1040, Line 58 or Federal Form 5329; and, Federal Forms 8889 and 8853.

11 7/24 4 This is an alpha/numeric field. Department ID Code. Must be “II-2” .12 16/24 7 This is a dollar amount field. This is the amount from Part II, Line 2 (Recapture of Federal

Investment Tax Credit) . Use the amount from Federal Form 4255.13 7/26 4 This is an alpha/numeric field. Department ID Code. Must be “II-3” .14 16/26 7 This is a dollar amount field. This is the amount from Part II, Line 3 (Tax from Federal Form

4972, Line 7 or 30) . Use the amount from Federal Form 4972, Line 7 or 30.15 7/28 4 This is an alpha/numeric field. Department ID Code. Must be “II-4” .16 15/28 8 This is a dollar amount field. This is the amount from Part II, Line 4 (Total of Lines II-1 through

II-3) .17 7/30 4 This is an alpha/numeric field. Department ID Code. Must be “II-5” .18 15/30 8 This is a dollar amount field. This is the amount from Part II, Line 5. Multiply Line II-4 by

24% . 19 7/32 4 This is an alpha/numeric field. Department ID Code. Must be “II-6” .20 15/32 8 This is a dollar amount field. This is the amount from Part II, Line 6 (Recapture of VT Credits).21 7/34 4 This is an alpha/numeric field. Department ID Code. Must be “II-7” .

[Page 42]

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DRAFT 21 NOV 201222 15/34 8 This is a dollar amount field. This is the amount from Part II, Line 7. Add Lines II-5 and II-6.

Enter this amount on Form IN-111, Line 17 (Form IN-111, Field #61).23 7/36 4 This is an alpha/numeric field. Department ID Code. Must be “II-8” .24 16/36 7 This is a dollar amount field. This is the amount from Part II, Line 8 (Credit for Child and

Dependent Care Expenses) . Use the amount from Federal Form 1040, Line 48; or 1040A, Line 29. NOTE: You cannot use both IN-111, Line 31g and IN-112, Part II, Line 8 on the same return .

25 7/38 4 This is an alpha/numeric field. Department ID Code. Must be “II-9” .26 16/38 7 This is a dollar amount field. This is the amount from Part II, Line 9 (Credit for the Elderly or

the Disabled) . Use the amount from Federal Schedule R.27 7/40 5 This is an alpha/numeric field. Department ID Code. Must be “II-10” .28 16/40 7 This is a dollar amount field. This is the amount from Part II, Line 10 (Investment Tax Credit

- VT-based only) . Use the amount from Federal Form 3468.29 7/42 5 This is an alpha/numeric field. Department ID Code. Must be “II-11” .30 16/42 7 This is a dollar amount field. This is the amount from Part II, Line 11 (VT Farm Income

Averaging Credit) . Use the amount from VT Farm Income Averaging Worksheet in 2012 VT Income Tax Return Booklet instructions.

31 7/44 5 This is an alpha/numeric field. Department ID Code. Must be “II-12” .32 15/44 8 This is a dollar amount field. This is the amount from Part II, Line 12 (Total of Lines II-8

through II-11) .33 7/46 5 This is an alpha/numeric field. Department ID Code. Must be “II-13” .34 15/46 8 This is a dollar amount field. This is the amount from Part II, Line 13. Multiply Line II-12 by

24% .35 7/48 5 This is an alpha/numeric field. Department ID Code. Must be “II-14” .36 15/48 8 This is a dollar amount field. This is the amount from Part II, Line 14 (VT-based Business

Solar Energy Credit carryforward) .37 7/50 5 This is an alpha/numeric field. Department ID Code. Must be “II-15” .38 15/50 8 This is a dollar amount field. This is the amount from Part II, Line 15. Add Lines II-13 and

II-14 . Enter this amount on Form IN-111, Line 19 (Form IN-111, Field #65). PART III (Fields #39 - #68) NOTE: If PART III is used, EITHER Lines III-1 and III-2 OR Lines III-3A through III-9 will be used . A qualifying taxpayer

is either a full-year resident OR a part-year resident, but CANNOT be both . Lines III-A, III-B, and III-C will be used regardless of residency status .

39 36/14 5 This is an alpha field. Department ID Code. Must be “III-A” .40 50/14 2 This is a numeric field. This is the number from Part III, Line A (Number of qualifying children).

Must be “00”, “01”, “02” or “03” only . Enter “00” as a default .41 36/16 5 This is an alpha field. Department ID Code. Must be “III-B” .42 50/16 2 This is a numeric field. This is the number from Part III, Line B (Number of qualifying children

under the age of 18) . Must be “00”, “01”, “02” or “03” only . Enter “00” as a default .43 36/18 5 This is an alpha field. Department ID Code. Must be “III-C” .44 51/18 1 This is an alpha field. This is from Part III, Line C (the answer to the question “Were you …

at least age 25 but under age 65 …”). Must be “Y” or “N” only . Enter “N” as a default .45 36/20 5 This is an alpha/numeric field. Department ID Code. Must be “III-1” .46 48/20 4 This is a dollar amount field. This is the amount from Part III, Line 1 (Earned income tax

credit) . Use the amount from Federal Form 1040, Line 64a; 1040A, Line 38a; or 1040EZ, Line 8a.

47 36/22 5 This is an alpha/numeric field. Department ID Code. Must be “III-2” .48 48/22 4 This is a dollar amount field. This is the amount from Part III, Line 2 (VT EARNED INCOME

TAX CREDIT) . Multiply Line III-1 by 32% . Enter this amount on Form IN-111, Line 31c (Form IN-111, Field #99).

49 36/24 6 This is an alpha/numeric field. Department ID Code. Must be “III-3A” .

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DRAFT 21 NOV 201250 47/24 5 This is a dollar amount field. This is the amount from Part III, Line 3A (FEDERAL AMOUNT

of Wages, salaries, tips, etc .) . Use the amount from VT Schedule IN-113, Column A, Line 1 (Schedule IN-113, Field #10).

51 36/26 6 This is an alpha/numeric field. Department ID Code. Must be “III-4A” .52 46/26 6 This is a dollar amount field. This is the amount from Part III, Line 4A (FEDERAL AMOUNT

of Other earned income) . Use the combined amounts from VT Schedule IN 113, Column A, Lines 6, 10, and 12 (Schedule IN-113, Fields #20, #28, and #32). Put a hyphen (-) at the beginning of the amount to indicate a loss .

53 36/28 6 This is an alpha/numeric field. Department ID Code. Must be “III-5A” .54 47/28 5 This is a dollar amount field. This is the amount from Part III, Line 5A (FEDERAL AMOUNT

of Total earned income) .55 36/30 6 This is an alpha/numeric field. Department ID Code. Must be “III-3B” .56 47/30 5 This is a dollar amount field. This is the amount from Part III, Line 3B (VT PORTION of

Wages, salaries, tips, etc .) . Use the amount from VT Schedule IN-113, Column B, Line 1 (Schedule IN-113, Field #66).

57 36/32 6 This is an alpha/numeric field. Department ID Code. Must be “III-4B” .58 46/32 6 This is a dollar amount field. This is the amount from Part III, Line 4B (VT PORTION of Other

earned income) . Use the combined amounts from VT Schedule IN-113, Column B, Lines 6, 10, and 12 (Schedule IN-113, Fields #76, #84, and #88). Put a hyphen (-) at the beginning of the amount to indicate a loss .

59 36/34 6 This is an alpha/numeric field. Department ID Code. Must be “III-5B” .60 47/34 5 This is a dollar amount field. This is the amount from Part III, Line 5B (VT PORTION of Total

earned income) . Add Lines III-3 and III-4 .61 36/36 5 This is an alpha/numeric field. Department ID Code. Must be “III-6” .62 47/36 5 This is a numeric field. This is the percentage from Part III, Line 6 (Earned income tax credit

adjustment) . Divide Line III-5B by Line III-5A . Cannot be more than 100 .00% (“10000”) .63 36/38 5 This is an alpha/numeric field. Department ID Code. Must be “III-7” .64 48/38 4 This is a dollar amount field. This is the amount from Part III, Line 7 (Earned income tax

credit) . Use the amount from Federal Form 1040, Line 64a; 1040A, Line 38a; or 1040EZ, Line 8a.

65 36/40 5 This is an alpha/numeric field. Department ID Code. Must be “III-8” .66 48/40 4 This is a dollar amount field. This is the amount from Part III, Line 8. Multiply Line III-7 by

32% .67 36/42 5 This is an alpha/numeric field. Department ID Code. Must be “III-9” .68 48/42 4 This is a dollar amount field. This is the amount from Part III, Line 9 (VT EARNED INCOME

TAX CREDIT) . Multiply Line III-8 by Line III-6 . Enter this amount on Form IN-111, Line 31c (Form IN-111, Field #99).

PART IV (Fields #69 - #106) 69 62/14 4 This is an alpha field. Department ID Code. Must be “FEIN” .70 69/14 9 This is a numeric field. For credits for Lines IV-2 through IV-6 earned through an S-Corporation,

LLC, LLP, or Partnership, this is the FEIN of the entity . Enter the name of the entity on Page 2 of this form, Part IV, in the place indicated . If credits on Lines IV-2 through IV-6 were not earned through an S-Corporation, LLC, LLP, or Partnership, leave this field blank.

71 62/16 5 This is an alpha/numeric field. Department ID Code. Must be “IV-1A” .72 72/16 6 This is a dollar amount field. This is the amount from Part IV, Line 1, Column A (2012

contribution to VT Higher Education Investment) .73 62/18 5 This is an alpha/numeric field. Department ID Code. Must be “IV-2A” .74 72/18 6 This is a dollar amount field. This is the amount from Part IV, Line 2, Column A (Commercial

Film Production credit earned in 2012) .75 62/20 5 This is an alpha/numeric field. Department ID Code. Must be “IV-3A” .76 72/20 6 This is a dollar amount field. This is the amount from Part IV, Line 3, Column A (Charitable

Housing credit earned in 2012) .77 62/22 5 This is an alpha/numeric field. Department ID Code. Must be “IV-4A” .

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DRAFT 21 NOV 201278 72/22 6 This is a dollar amount field. This is the amount from Part IV, Line 4, Column A (Qualified

Sale of Mobile Home Park credit earned in 2012) .79 62/24 5 This is an alpha/numeric field. Department ID Code. Must be “IV-5A” .80 72/24 6 This is a dollar amount field. This is the amount from Part IV, Line 5, Column A (Research &

Development earned in 2012) .81 62/26 5 This is an alpha/numeric field. Department ID Code. Must be “IV-6A” .82 72/26 6 This is a dollar amount field. This is the amount from Part IV, Line 6, Column A (Veteran

Business Credit earned in 2012) .(There is no Line IV-1B .) 83 62/28 5 This is an alpha/numeric field. Department ID Code. Must be “IV-2B” .84 77/28 1 This is a dollar amount field. This is the amount from Part IV, Line 2, Column B (Commercial

Film Production carryforward) . This is not available as a carryforward . Must be “0” .85 62/30 5 This is an alpha/numeric field. Department ID Code. Must be “IV-3B” .86 72/30 6 This is a dollar amount field. This is the amount from Part IV, Line 3, Column B (Charitable

Housing credit carryforward) .87 62/32 5 This is an alpha/numeric field. Department ID Code. Must be “IV-4B” .88 72/32 6 This is a dollar amount field. This is the amount from Part IV, Line 4, Column B (Qualified

Sale of Mobile Home Park credit carryforward) .89 62/34 5 This is an alpha/numeric field. Department ID Code. Must be “IV-5B” .90 72/34 6 This is a dollar amount field. This is the amount from Part IV, Line 5, Column B (Research &

Development Credit carryforward) .91 62/36 5 This is an alpha/numeric field. Department ID Code. Must be “IV-6B” .92 77/36 1 This is a dollar amount field. This is the amount from Part IV, Line 6, Column B (Veteran

Business Credit carryforward) . This is not available as a carryforward . Must be “0” .93 62/38 5 This is an alpha/numeric field. Department ID Code. Must be “IV-1C” .94 72/38 6 This is a dollar amount field. This is the amount from Part IV, Line 1, Column C (VT Higher

Education Investment credit) .95 62/40 5 This is an alpha/numeric field. Department ID Code. Must be “IV-2C” .96 72/40 6 This is a dollar amount field. This is the amount from Part IV, Line 2, Column C (Commercial

Film Production credit) .97 62/42 5 This is an alpha/numeric field. Department ID Code. Must be “IV-3C” .98 72/42 6 This is a dollar amount field. This is the amount from Part IV, Line 3, Column C (Charitable

Housing credit) .99 62/44 5 This is an alpha/numeric field. Department ID Code. Must be “IV-4C” .100 72/44 6 This is a dollar amount field. This is the amount from Part IV, Line 4, Column C (Qualified

Sale of Mobile Home Park credit) .101 62/46 5 This is an alpha/numeric field. Department ID Code. Must be “IV-5C” .102 72/46 6 This is a dollar amount field. This is the amount from Part IV, Line 5, Column C (Research &

Development) .103 62/48 5 This is an alpha/numeric field. Department ID Code. Must be “IV-6C” .104 72/48 6 This is a dollar amount field. This is the amount from Part IV, Line 6, Column C (Veteran

Business Credit) .105 62/50 4 This is an alpha/numeric field. Department ID Code. Must be “IV-7” .106 72/50 6 This is a dollar amount field. This is the amount from Part IV, Line 7, Column C (Total Credits).

Add Column C, Lines 1-6 . If there are credits on VT Schedule IN-119, enter this amount on Schedule IN-119. If there are NO credits on VT Schedule IN-119, enter this amount on IN-111, Line 24 (Form IN-111, Field #75).

ID # 7/63 4 This is the 4-digit Vendor ID Number which is assigned by NACTP

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ID #

DRAFT 21 NOV 2012


Schedule IN-113

2012 VT Income Adjustment Calculations

Schedule IN-113 ATTACH TO FORM IN-111Nonresidents and Part-Year Residents Must Complete Parts I and IIFull-Year Residents with Adjustments Complete Part II only


11 12

109

2

4

6

8

1

3

5

7

14

15 16

13

17 18

19 20

21 22

23 24

25 26

27 28

29 30

31 32

33 34

35 36

37 38

39 40

41 42

43 44

45 46

47 48

49 50

55 56

57 58

59 60

61 62

65 66

67 68

69 70

71 72

73 74

75 76

77 78

79 80

81 82

83 84

85 86

87 88

89 90

91 92

93 94

95 96

97 98

99 100

103 104

105 106

107 108

109 110

111 112

113 114

115 116

123

125

124

126

127 128

129 130

131 132

133 134

135 136

137 138

139 140

141 142

143 144

145 146

147 148

117 118

149 150

51 52

63 64

121 122

119 120

53 54

102101 152151

154153

158157

156155

*121133199** 1 2 1 1 3 3 1 9 9 *

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#25).3 7/15 4 This is an alpha field. Department ID Code. Must be “RESB” .4 14/15 8 This is a numeric field. Beginning date of VT residency in 2012. Must be 8 digits (MMDDYYYY).

Date must be 01012012 through 12312012, inclusive . If Part I is not completed (full-year resident), leave this field blank.

5 7/17 4 This is an alpha field. Department ID Code. Must be “RESE” .6 14/17 8 This is a numeric field. Ending date of VT residency in 2012. Must be 8 digits (MMDDYYYY).

Date must be 01012012 through 12312012, inclusive . If Part I is not completed (full-year resident), leave this field blank.

7 7/19 2 This is an alpha field. Department ID Code. Must be “ST”.8 14/19 2 This is an alpha field. This is the two-letter abbreviation for the state or Canadian province

during non-VT residency in 2012 . If Part I is not completed (full-year resident), leave this field blank.

9 7/21 2 This is an alpha/numeric field. Department ID Code. Must be “1A” .10 14/21 8 This is a dollar amount field. This is the amount from Line 1, Column A (FEDERAL AMOUNT

of Wages, salaries, tips, etc .) .11 7/23 2 This is an alpha/numeric field. Department ID Code. Must be “2A” .12 14/23 8 This is a dollar amount field. This is the amount from Line 2, Column A (FEDERAL AMOUNT

of Taxable interest) .13 7/25 2 This is an alpha/numeric field. Department ID Code. Must be “3A” .14 14/25 8 This is a dollar amount field. This is the amount from Line 3, Column A (FEDERAL AMOUNT

of Ordinary dividends) .15 7/27 2 This is an alpha/numeric field. Department ID Code. Must be “4A” .16 14/27 8 This is a dollar amount field. This is the amount from Line 4, Column A (FEDERAL AMOUNT

of Taxable refunds of state and local income taxes) .17 7/29 2 This is an alpha/numeric field. Department ID Code. Must be “5A” .18 14/29 8 This is a dollar amount field. This is the amount from Line 5, Column A (FEDERAL AMOUNT

of Alimony received) .19 7/31 2 This is an alpha/numeric field. Department ID Code. Must be “6A” .20 13/31 9 This is a dollar amount field. This is the amount from Line 6, Column A (FEDERAL AMOUNT

of Business income or loss) . Put a hyphen (-) at the beginning of the amount to indicate a loss .21 7/33 2 This is an alpha/numeric field. Department ID Code. Must be “7A” .22 13/33 9 This is a dollar amount field. This is the amount from Line 7, Column A (FEDERAL AMOUNT

of Capital gain or loss) . Put a hyphen (-) at the beginning of the amount to indicate a loss .23 7/35 2 This is an alpha/numeric field. Department ID Code. Must be “8A” .

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DRAFT 21 NOV 201224 14/35 8 This is a dollar amount field. This is the amount from Line 8, Column A (FEDERAL AMOUNT

of Taxable IRA distributions) .25 7/37 2 This is an alpha/numeric field. Department ID Code. Must be “9A” .26 14/37 8 This is a dollar amount field. This is the amount from Line 9, Column A (FEDERAL AMOUNT

of Taxable pensions and annuities) .27 7/39 3 This is an alpha/numeric field. Department ID Code. Must be “10A” .28 13/39 9 This is a dollar amount field. This is the amount from Line 10, Column A (FEDERAL AMOUNT

of Partnerships/S Corporations, and LLCs) . Put a hyphen (-) at the beginning of the amount to indicate a loss .


of Rents, royalties, estates, trusts, etc .) . Put a hyphen (-) at the beginning of the amount to indicate a loss .


of Farm income or loss) . Put a hyphen (-) at the beginning of the amount to indicate a loss .33 7/45 3 This is an alpha/numeric field. Department ID Code. Must be “13A” .34 14/45 8 This is a dollar amount field. This is the amount from Line 13, Column A (FEDERAL AMOUNT

of Unemployment compensation) .35 7/47 3 This is an alpha/numeric field. Department ID Code. Must be “14A” .36 14/47 8 This is a dollar amount field. This is the amount from Line 14, Column A (FEDERAL AMOUNT

of Taxable social security) .37 7/49 3 This is an alpha/numeric field. Department ID Code. Must be “15A” .38 13/49 9 This is a dollar amount field. This is the amount from Line 15, Column A (FEDERAL AMOUNT

of Other) . Specify source of “Other” on taxpayer-readable portion (Page 2) of this schedule . Put a hyphen (-) at the beginning of the amount to indicate a loss .


of TOTAL INCOME) . Add Lines 1A through 15A. Put a hyphen (-) at the beginning of the amount to indicate a loss .


of IRA/Keogh/SEP/SIMPLE deduction) . Show separate amounts for “Self” and “Spouse” on Page 2 of this schedule . Use the combined amounts from Federal Form 1040, Lines 32 and 28; or Form 1040A, Line 17.


of Student Loan Interest) . Use the amount from Federal Form 1040, Line 33; or Form 1040A, Line 18.


of Employee Deductions) . Use the amount from Federal Form 1040, Line 24.47 7/59 3 This is an alpha/numeric field. Department ID Code. Must be “20A” .48 14/59 8 This is a dollar amount field. This is the amount from Line 20, Column A (FEDERAL AMOUNT

of Self-Employment Deductions) . Use the combined amounts from Federal Form 1040, Lines 27 and 29.


of Health Savings Account) . Use the amount from Federal Form 1040, Line 25.51 29/13 3 This is an alpha/numeric field. Department ID Code. Must be “22A” .52 36/13 8 This is a dollar amount field. This is the amount from Line 22, Column A (FEDERAL AMOUNT

of Moving Expenses) . Use the amount from Federal Form 1040, Line 26.53 29/15 3 This is an alpha/numeric field. Department ID Code. Must be “23A” .

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DRAFT 21 NOV 201254 36/15 8 This is a dollar amount field. This is the amount from Line 23, Column A (FEDERAL AMOUNT

of Penalty on Early Withdrawal of Savings) . Use the amount from Federal Form 1040, Line 30.


of Alimony Paid) . Use the amount from Federal Form 1040, Line 31a.57 29/19 3 This is an alpha/numeric field. Department ID Code. Must be “25A” .58 36/19 8 This is a dollar amount field. This is the amount from Line 25, Column A (FEDERAL AMOUNT

of Domestic production activities) . Use the amount from Federal Form 1040, Line 35.59 29/21 3 This is an alpha/numeric field. Department ID Code. Must be “26A” .60 36/21 8 This is a dollar amount field. This is the amount from Line 26, Column A (FEDERAL AMOUNT

of Educator Expenses and Tuition & Fees) . Use the combined amounts from Federal Form 1040, Lines 23 and 34; or, Form 1040A, Lines 16 and 19.


of Deductions not listed above but included on Federal Form 1040, Line 36) .63 29/25 3 This is an alpha/numeric field. Department ID Code. Must be “28A” .64 36/25 8 This is a dollar amount field. This is the amount from Line 28, Column A (FEDERAL AMOUNT

of TOTAL ADJUSTMENTS) . Add Lines 17A through 27A.65 29/27 2 This is an alpha/numeric field. Department ID Code. Must be “1B” .66 36/27 8 This is a dollar amount field. This is the amount from Line 1, Column B (VT PORTION of

Wages, salaries, tips, etc .) .67 29/29 2 This is an alpha/numeric field. Department ID Code. Must be “2B” .68 36/29 8 This is a dollar amount field. This is the amount from Line 2, Column B (VT PORTION of

Taxable interest) .69 29/31 2 This is an alpha/numeric field. Department ID Code. Must be “3B” .70 36/31 8 This is a dollar amount field. This is the amount from Line 3, Column B (VT PORTION of

Ordinary dividends) .71 29/33 2 This is an alpha/numeric field. Department ID Code. Must be “4B” .72 36/33 8 This is a dollar amount field. This is the amount from Line 4, Column B (VT PORTION of

Taxable refunds of state and local income taxes) .73 29/35 2 This is an alpha/numeric field. Department ID Code. Must be “5B” .74 36/35 8 This is a dollar amount field. This is the amount from Line 5, Column B (VT PORTION of

Alimony received) .75 29/37 2 This is an alpha/numeric field. Department ID Code. Must be “6B” .76 35/37 9 This is a dollar amount field. This is the amount from Line 6, Column B (VT PORTION of

Business income or loss) . Put a hyphen (-) at the beginning of the amount to indicate a loss .77 29/39 2 This is an alpha/numeric field. Department ID Code. Must be “7B” .78 35/39 9 This is a dollar amount field. This is the amount from Line 7, Column B (VT PORTION of

Capital gain or loss) . Put a hyphen (-) at the beginning of the amount to indicate a loss .79 29/41 2 This is an alpha/numeric field. Department ID Code. Must be “8B” .80 36/41 8 This is a dollar amount field. This is the amount from Line 8, Column B (VT PORTION of

Taxable IRA distributions) .81 29/43 2 This is an alpha/numeric field. Department ID Code. Must be “9B” .82 36/43 8 This is a dollar amount field. This is the amount from Line 9, Column B (VT PORTION of

Taxable pensions and annuities) .83 29/45 3 This is an alpha/numeric field. Department ID Code. Must be “10B” .84 35/45 9 This is a dollar amount field. This is the amount from Line 10, Column B (VT PORTION

of Partnerships/S Corporations & LLCs) . Put a hyphen (-) at the beginning of the amount to indicate a loss .

85 29/47 3 This is an alpha/numeric field. Department ID Code. Must be “11B” .86 35/47 9 This is a dollar amount field. This is the amount from Line 11, Column B (VT PORTION of

Rents, royalties, estates, trusts, etc .) . Put a hyphen (-) at the beginning of the amount to indicate a loss .

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DRAFT 21 NOV 201287 29/49 3 This is an alpha/numeric field. Department ID Code. Must be “12B” .88 35/49 9 This is a dollar amount field. This is the amount from Line 12, Column B (VT PORTION of

Farm income or loss) . Put a hyphen (-) at the beginning of the amount to indicate a loss .89 29/51 3 This is an alpha/numeric field. Department ID Code. Must be “13B” .90 36/51 8 This is a dollar amount field. This is the amount from Line 13, Column B (VT PORTION of

Unemployment compensation) .91 29/53 3 This is an alpha/numeric field. Department ID Code. Must be “14B” .92 36/53 8 This is a dollar amount field. This is the amount from Line 14, Column B (VT PORTION of

Taxable social security) .93 29/55 3 This is an alpha/numeric field. Department ID Code. Must be “15B” .94 35/55 9 This is a dollar amount field. This is the amount from Line 15, Column B (VT PORTION of

Other) . Put a hyphen (-) at the beginning of the amount to indicate a loss .95 29/57 3 This is an alpha/numeric field. Department ID Code. Must be “16B” .96 35/57 9 This is a dollar amount field. This is the amount from Line 16, Column B (VT PORTION of

TOTAL INCOME) . Add Lines 1B through 15B. Put a hyphen (-) at the beginning of the amount to indicate a loss .

97 29/59 3 This is an alpha/numeric field. Department ID Code. Must be “17B” .98 36/59 8 This is a dollar amount field. This is the amount from Line 17, Column B (VT PORTION of

IRA/Keogh/SEP/SIMPLE deduction) .99 29/61 3 This is an alpha/numeric field. Department ID Code. Must be “18B” .100 36/61 8 This is a dollar amount field. This is the amount from Line 18, Column B (VT PORTION of

Student Loan Interest) .101 51/13 3 This is an alpha/numeric field. Department ID Code. Must be “19B” .102 58/13 8 This is a dollar amount field. This is the amount from Line 19, Column B (VT PORTION of

Employee Deductions) .103 51/15 3 This is an alpha/numeric field. Department ID Code. Must be “20B” .104 58/15 8 This is a dollar amount field. This is the amount from Line 20, Column B (VT PORTION of

Self-Employment Deductions) .105 51/17 3 This is an alpha/numeric field. Department ID Code. Must be “21B” .106 58/17 8 This is a dollar amount field. This is the amount from Line 21, Column B (VT PORTION of

Health Savings Account) .107 51/19 3 This is an alpha/numeric field. Department ID Code. Must be “22B” .108 58/19 8 This is a dollar amount field. This is the amount from Line 22, Column B (VT PORTION of

Moving Expenses) .109 51/21 3 This is an alpha/numeric field. Department ID Code. Must be “23B” .110 58/21 8 This is a dollar amount field. This is the amount from Line 23, Column B (VT PORTION of

Penalty on Early Withdrawal of Savings) .111 51/23 3 This is an alpha/numeric field. Department ID Code. Must be “24B” .112 58/23 8 This is a dollar amount field. This is the amount from Line 24, Column B (VT PORTION of

Alimony Paid) .113 51/25 3 This is an alpha/numeric field. Department ID Code. Must be “25B” .114 58/25 8 This is a dollar amount field. This is the amount from Line 25, Column B (VT PORTION of

Domestic production activities) .115 51/27 3 This is an alpha/numeric field. Department ID Code. Must be “26B” .116 58/27 8 This is a dollar amount field. This is the amount from Line 26, Column B (VT PORTION of

Educator Expenses and Tuition & Fees) .117 51/29 3 This is an alpha/numeric field. Department ID Code. Must be “27B” .118 58/29 8 This is a dollar amount field. This is the amount from Line 27, Column B (VT PORTION of

Deductions not listed above but included on Federal Form 1040, Line 36 ) .119 51/31 3 This is an alpha/numeric field. Department ID Code. Must be “28B” .120 58/31 8 This is a dollar amount field. This is the amount from Line 28, Column B (VT PORTION of

TOTAL ADJUSTMENTS) . Add Lines 17B through 27B.121 51/33 2 This is a numeric field. Department ID Code. Must be “29” .

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DRAFT 21 NOV 2012122 57/33 9 This is a dollar amount field. This is the amount from Line 29 (Adjusted Gross Income).

Subtract Line 28A from Line 16A. Put a hyphen (-) at the beginning of the amount to indicate a loss .

123 51/35 2 This is a numeric field. Department ID Code. Must be “30” .124 57/35 9 This is a dollar amount field. This is the amount from Line 30 (VT PORTION of Adjusted

Gross Income) . Subtract Line 28B from Line 16B. Put a hyphen (-) at the beginning of the amount to indicate a loss .

125 51/37 2 This is a numeric field. Department ID Code. Must be “31” .126 57/37 9 This is a dollar amount field. This is the amount from Line 31 (Non-VT Income). Put a hyphen

(-) at the beginning of the amount to indicate a loss . Also enter this amount on Line 33 (Field #130) below.

127 51/39 2 This is a numeric field. Department ID Code. Must be “32” .128 57/39 9 This is a dollar amount field. This is the amount from Line 32 (Adjusted Gross Income). If

Part I is completed, enter amount from Line 29 above (Field #122). Otherwise, enter amount from Form IN-111, Line 10 (Form IN-111, Field #37). Put a hyphen (-) at the beginning of the amount to indicate a loss .

129 51/41 2 This is a numeric field. Department ID Code. Must be “33” .130 57/41 9 This is a dollar amount field. This is the amount from Line 33 (Non-VT Income). Put a hyphen

(-) at the beginning of the amount to indicate a loss . Use the amount from Line 31 (Field #126) above or, if full-year VT residents, enter zero (0).

131 51/43 2 This is a numeric field. Department ID Code. Must be “34” .132 58/43 8 This is a dollar amount field. This is the amount from Line 34 (Military pay). Enter the number

of months on active duty on the taxpayer-readable portion (Page 2) .133 51/45 2 This is a numeric field. Department ID Code. Must be “35” .134 58/45 8 This is a dollar amount field. This is the amount from Line 35 (Federal Employment Opportunity

income adjustment) .135 51/47 2 This is a numeric field. Department ID Code. Must be “36” .136 58/47 8 This is a dollar amount field. This is the amount from Line 36 (Railroad Retirement income).137 51/49 2 This is a numeric field. Department ID Code. Must be “37” .138 58/49 8 This is a dollar amount field. This is the amount from Line 37 [VT State payments to a family

for support of developmentally disabled person(s)] .139 51/51 2 This is a numeric field. Department ID Code. Must be “38” .140 58/51 8 This is a dollar amount field. This is the amount from Line 38 (Americans with Disabilities

Credit) .141 51/53 2 This is a numeric field. Department ID Code. Must be “39” .142 58/53 8 This is a dollar amount field. This is the amount from Line 39 (Nonresident Commercial Film

Income) .143 51/55 2 This is a numeric field. Department ID Code. Must be “40” .144 58/55 8 This is a dollar amount field. This is the amount from Line 40 (Bond/note interest income).

Check the appropriate box(es) for the source . (See Fields #151 - #158)145 51/57 2 This is a numeric field. Department ID Code. Must be “41” .146 57/57 9 This is a dollar amount field. This is the amount from Line 41 (Total of Lines 33-40). Put a

hyphen (-) at the beginning of the amount to indicate a loss .147 51/59 2 This is a numeric field. Department ID Code. Must be “42” .148 57/59 9 This is a dollar amount field. This is the amount from Line 42 (VT Income). Subtract Line 41

from Line 32 . Put a hyphen (-) at the beginning of the amount to indicate a loss .149 51/61 2 This is a numeric field. Department ID Code. Must be “43” .150 61/61 5 This is a numeric (percentage) field. This is the percentage from Line 43 (Income Adjustment

%) . Divide Line 42 by Line 32 . CANNOT BE MORE THAN 100% (“10000”) OR LESS THAN 0% (“0”). Also enter this amount on Form IN-111, Line 21 (Form IN-111, Field #69).

151 73/13 4 This is an alpha field. Department ID Code. Must be “VSAC” .152 80/13 1 This is an alpha field. This is answer to Line 40 checkbox, Bond/note interest income from

VSAC . Must be “Y” or “N” only . Enter “N” as a default.

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DRAFT 21 NOV 2012153 73/15 2 This is an alpha field. Department ID Code. Must be “BA” .154 80/15 1 This is an alpha field. This is answer to Line 40 checkbox, Bond/note interest income from

Build America . Must be “Y” or “N” only . Enter “N” as a default.155 73/17 3 This is an alpha field. Department ID Code. Must be “TEL” .156 80/17 1 This is an alpha field. This is answer to Line 40 checkbox, Bond/note interest income from VT

Telecom Authority . Must be “Y” or “N” only . Enter “N” as a default. 157 73/19 3 This is an alpha field. Department ID Code. Must be “PSA” .158 80/19 1 This is an alpha field. This is answer to Line 40 checkbox, Bond/note interest income from VT

Public Power Supply Authority . Must be “Y” or “N” only . Enter “N” as a default.


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ID #

DRAFT 21 NOV 2012 VERMONT Form IN-114


Form IN-114


Form IN-114



VERMONT Form IN-114







MAIL VOUCHER TO: Vermont Department of Taxes PO Box 1779 Montpelier, VT 05601-1779


$

PAYMENT DUE DATES: 1st Quarter APR 15, 2013 2nd Quarter JUN 15, 2013 3rd Quarter SEP 15, 2013 4th Quarter JAN 15, 2014

*101143199** 1 0 1 1 4 3 1 9 9 *

1 2 3 4

5 6 7 8

10 11

ID #

12

13

14 15 16

9

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NOTE: This form is designed as a “generic year” form. Please leave the area for the year in the upper left corner blank on the template (blank form). (Yellow highlighted areas on Page 52 indicate the areas which should be blank on the template. The yellow highlighting is for reference purposes only and should not be included on the printed form.) The year should be printed at the same time as the variable data. The form must be submitted annually for approval. Also, we have added drawn boxes on the coupon for better “form recognition” in our scanners. These must be printed on all approved forms.


1 7/8 2 This is an alpha field. Department ID Code. Must be “TY” .2 12/8 4 This is a numeric field. This is the Tax Year to which this payment should be applied (2013) .

Must be 4 digits . Must be “2013” .3 28/8 3 This is an alpha field. Department ID Code. Must be “AMT” .4 34/8 7 This is a dollar amount field. This is the amount of payment.5 7/10 20 This is an alpha field. Taxpayer’s Last Name. This is a REQUIRED ENTRY .6 31/10 20 This is an alpha field. Taxpayer’s First Name. This is a REQUIRED ENTRY .7 55/10 1 This is an alpha field. Taxpayer’s Middle Initial.8 65/10 9 This is a numeric field. Taxpayer’s Social Security Number. Must be 9 digits. This is a


leave this field blank.10 31/12 20 This is an alpha field. Spouse or CU Partner First Name. If there is no Spouse or CU Partner,

leave this field blank.11 55/12 1 This is an alpha field. Spouse or CU Partner Middle Initial. If there is no Spouse or CU

Partner, leave this field blank.12 65/12 9 This is a numeric field. Spouse or CU Partner Social Security Number. Must be 9 digits; or,

if there is no Spouse or CU Partner, leave this field blank.13 7/14 35 This is an alpha/numeric field. Mailing Address.14 7/16 25 This is an alpha field. City or Town for mailing address.15 36/16 2 This is an alpha field. State for mailing address. Use the standard 2-character state abbreviation.16 42/16 9 This is a numeric field. ZIP Code for mailing address. Must have 5 or 9 digits only. DO NOT

enter a hyphen (-) or space between the 5-digit ZIP Code and the “+4” digits.

Because the page should be cut by taxpayer before filing the return, please put your 4-digit NACTP Vendor ID Number in two places as noted below.

ID # 7/21 4 This is the 4-digit Vendor ID Number which is assigned by NACTP . ID # 7/63 4 This is the 4-digit Vendor ID Number which is assigned by NACTP . (Cut-line specifications on next page)

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DRAFT 21 NOV 2012** A Cut-Line must be drawn across the page at the bottom of row 22. **

Below the cut-line add the following instructions:Cut at line above. Mail top portion with check or money order to: Vermont Department of Taxes, PO Box 1779, Montpelier, VT 05601-1779Keep this portion for your records.

Also, on taxpayer’s copy, add in large letters (as shown on sample): TAXPAYER’S COPY KEEP THIS PORTION FOR YOUR RECORDS MAIL TOP PORTION WITH YOUR PAYMENT

You will note that we also added the payment due dates to the taxpayer-readable portion .

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ID #

DRAFT 21 NOV 2012 VERMONT


$

Make check payable to: VERMONT DEPARTMENT OF TAXES

VERMONT






Use this form if you are NOT submitting payment with Form IN-111.


Form IN-116





Form IN-116

123456789.

1 2 3 4

5 6 7 8

9 10 11

ID #

12

13

14 15 16

*081163199** 0 9 1 1 6 3 1 9 9 *

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NOTE: This form is designed as a “generic year” form. Please leave the area for the year in the upper left corner blank on the template (blank form). (Yellow highlighted areas on Page 55 indicate the areas which should be blank on the template. The yellow highlighting is for reference purposes only and should not be included on the printed form.) The year should be printed at the same time as the variable data. The form must be submitted annually for approval. Also, we have added drawn boxes on the coupon for better “form recognition” in our scanners. These must be printed on all approved forms.


1 7/9 2 This is an alpha field. Department ID Code. Must be “TY” .2 12/9 4 This is a numeric field. This is the Tax Year. Must be 4 digits. Must be “2012” .3 28/9 3 This is an alpha field. Department ID Code. Must be “AMT” .4 34/9 9 This is a dollar amount field. This is the amount of payment.5 7/11 20 This is an alpha field. Taxpayer’s Last Name. This is a REQUIRED ENTRY .6 31/11 20 This is an alpha field. Taxpayer’s First Name. This is a REQUIRED ENTRY .7 55/11 1 This is an alpha field. Taxpayer’s Middle Initial.8 65/11 9 This is a numeric field. Taxpayer’s Social Security Number. Must be 9 digits. This is a





if there is no Spouse or CU Partner, leave this field blank.13 7/15 35 This is an alpha/numeric field. Mailing Address. 14 7/17 25 This is an alpha field. City or Town for mailing address.15 36/17 2 This is an alpha field. State for mailing address. Use the standard 2-character state abbreviation.16 42/17 9 This is a numeric field. ZIP Code for mailing address. Must have 5 or 9 digits only. DO NOT


Because the coupon is separated, please put your 4-digit NACTP Vendor ID Number in two places as noted below.ID # 7/21 4 This is the 4-digit Vendor ID Number which is assigned by NACTP . ID # 7/63 4 This is the 4-digit Vendor ID Number which is assigned by NACTP .

(Cut-line specifications on next page)

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DRAFT 21 NOV 2012** A Cut-Line must be drawn across the page at the bottom of row 22. **

Below the cut-line add the following instructions:

Use this form if you are NOT submitting your payment with your Form IN-111.Cut at line above. Mail top portion with check or money order to: Vermont Department of Taxes, PO Box 1779, Montpelier, VT 05601-1779Keep this portion for your records.

Also, on taxpayer’s copy, add in large letters (as shown on sample): TAXPAYER’S COPY KEEP THIS PORTION FOR YOUR RECORDS MAIL TOP PORTION WITH YOUR PAYMENT

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ID #

DRAFT 21 NOV 20122012 VT Credit for Income Tax Paid to Other State or Canadian Province Schedule IN-117


1. Name of state or Canadian province. Use standard two-letter abbreviation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. 2. Enter Adjusted Gross Income taxed in another state or Canadian province

that is also subject to VT income tax. This entry cannot be more than entry on Form IN-111, Line 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.

3. 2012 Bonus Depreciation add back taxed in another state or Canadian province AND taxed in VT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.

4. Non-VT state/local obligations taxed in another state or Canadian province AND taxed in VT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.

5. Add Lines 2-4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. 6. Bonus Depreciation subtracted from income in another state or

Canadian province in tax year 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. 7. U. S. Government interest income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. 8. Add Lines 6 & 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 9. ModifiedAdjustedGrossIncomeforincometaxedinotherstateorCanadianprovinceANDtaxedin

VT (Subtract Line 8 from Line 5). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. 10. Adjusted Gross Income from Form IN-111, Line 10 . . . . . . . . . . . . . . . . . . . . 10. 11. Non-VT state/local obligations from Form IN-111, Line 12a. . . . . . . . . . . . . . .11. 12. Bonus Depreciation from Form IN-111, Line 12b . . . . . . . . . . . . . . . . . . . . . . 12. 13. Add Lines 10-12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13. 14. U.S. Government interest income from Form IN-111, Line 14a . . . . . . . . . . . 14. 15. Bonus Depreciation from Form IN-111, Line 14c. . . . . . . . . . . . . . . . . . . . . . 15. 16. Add Lines 14 & 15. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.17. Subtract Line 16 from Line 13. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17. 18. VT income tax from Form IN-111, Line 20. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18. 19. Computed tax credit (Divide Line 9 by Line 17 and multiply result by Line 18).

Result cannot be more than 100% of VT tax. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. IncometaxpaidtoanotherstateorCanadianprovincebasedonmodifiedadjustedgrossincomefrom

Line 9 above. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20. 21. VT CREDIT for income tax paid to another state or Canadian province. Enter the lesser of Line 19 or Line 20.

Also enter on Form IN-111, Line 23. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.

For Residents and Some Part-Year Residents ONLY.You must complete a separate Schedule IN-117 for each state or Canadian provinceand attach a copy of the other state return(s). See instructions. ATTACH TO FORM IN-111


Schedule IN-117

11 12

109

21

1413

19 20

21 22

23 24

25 26

31 32

33 34

35 36

37 38

39 40

41 42

43 44

15 16

27 28

17 18

3029

43

65

87

*121173199** 1 2 1 1 7 3 1 9 9 *

[Page 59]

IN-117 Page

59

IN-117 Page

59





NOTE: If filing for more than one state and/or Canadian province, complete a separate Schedule IN-117 for each state and/or Canadian province . The total of Line 21 from ALL Schedules IN-117 is then entered on Form IN-111, Line 23 (Form IN-111, Field #73) .



#25).3 7/18 1 This is a numeric field. Department ID Code. Must be “1”.4 20/18 2 This is an alpha field. This is the two-letter abbreviation for the state or Canadian

province (Line 1) .5 7/20 1 This is a numeric field. Department ID Code. Must be “2”.6 12/20 10 This is a dollar amount field. This is the amount from Line 2 (Adjusted Gross Income

taxed in another state or Canadian province and that is also subject to VT income tax .) This amount cannot be more than Form IN-111, Line 10 (Form IN-111, Field #37). Put a hyphen (-) at the beginning of the amount to indicate a loss .

7 7/22 1 This is a numeric field. Department ID Code. Must be “3”.8 13/22 9 This is a dollar amount field. This is the amount from Line 3 (2012 Bonus Depreciation

addback taxed in another state or Canadian province AND taxed in VT .) 9 7/24 1 This is a numeric field. Department ID Code. Must be “4”.10 13/24 9 This is a dollar amount field. This is the amount from Line 4 (Non-VT state/local

obligations taxed in another state or Canadian province AND taxed in VT .) 11 7/26 1 This is a numeric field. Department ID Code. Must be “5”.12 13/26 9 This is a dollar amount field. This is the amount from Line 5 (Add Lines 2-4.) 13 7/28 1 This is a numeric field. Department ID Code. Must be “6”.14 13/28 9 This is a dollar amount field. This is the amount from Line 6 (Bonus Depreciation

subtracted from income in another state or Canadian province in tax year 2012 .) 15 36/16 1 This is a numeric field. Department ID Code. Must be “7”.16 42/16 9 This is a dollar amount field. This is the amount from Line 7 (U. S. Government interest

income .) 17 36/18 1 This is a numeric field. Department ID Code. Must be “8”.18 42/18 9 This is a dollar amount field. This is the amount from Line 8 (Add Lines 6 and 7.) 19 36/20 1 This is a numeric field. Department ID Code. Must be “9”.20 42/20 9 This is a dollar amount field. This is the amount from Line 9 (Modified Adjusted

Gross Income for income taxed in other state or Canadian province AND taxed in VT .) Subtract Line 8 from Line 5 .

[Page 60]

IN-117 Page

60

IN-117 Page

60

DRAFT 21 NOV 201221 36/22 2 This is a numeric field. Department ID Code. Must be “10”.22 41/22 10 This is a dollar amount field. This is the amount from Line 10 (Adjusted Gross Income from

Form IN-111, Line 10 .) Put a hyphen (-) at the beginning of the amount to indicate a loss . Use the amount from Form IN-111, Line 10 (Form IN-111, Field #37).

23 36/24 2 This is a numeric field. Department ID Code. Must be “11”.24 42/24 9 This is a dollar amount field. This is the amount from Line 11 (Non-VT state/local

obligations from Form IN-111, Line 12a .) Use the amount from Form IN-111, Line 12a (Form IN-111, Field #41).

25 36/26 2 This is a numeric field. Department ID Code. Must be “12”.26 42/26 9 This is a dollar amount field. This is the amount from Line 12 (Bonus Depreciation

from Form IN-111, Line 12b .) Use the amount from Form IN-111, Line 12b (Form IN-111, Field #43).

27 36/28 2 This is a numeric field. Department ID Code. Must be “13”.28 42/28 9 This is a dollar amount field. This is the amount from Line 13 (Add Lines 10-12.) 29 65/16 2 This is a numeric field. Department ID Code. Must be “14”.30 70/16 9 This is a dollar amount field. This is the amount from Line 14 (U. S. Government

interest income from Form IN-111, Line 14a .) Use the amount from Form IN-111, Line 14a (Form IN-111, Field #49).

31 65/18 2 This is a numeric field. Department ID Code. Must be “15”.32 70/18 9 This is a dollar amount field. This is the amount from Line 15 (Bonus Depreciation

from Form IN-111, Line 14c .) Use the amount from Form IN-111, Line 14c (Form IN-111, Field #53)

33 65/20 2 This is a numeric field. Department ID Code. Must be “16”.34 70/20 9 This is a dollar amount field. This is the amount from Line 16 (Add Lines 14 and 15.) 35 65/22 2 This is a numeric field. Department ID Code. Must be “17”.36 70/22 9 This is a dollar amount field. This is the amount from Line 17 (Subtract Line 16 from

Line 13 .) 37 65/24 2 This is a numeric field. Department ID Code. Must be “18”.38 70/24 9 This is a dollar amount field. This is the amount from Line 18 (VT income tax from

Form IN-111, Line 20 .) Use the amount from Form IN-111, Line 20 (Form IN-111, Field #67)

39 65/26 2 This is a numeric field. Department ID Code. Must be “19”.40 70/26 9 This is a dollar amount field. This is the amount from Line 19 (Computed tax credit.)

Divide Line 9 by Line 17 and multiply result by Line 18 . Result cannot be more than 100% of VT tax.

41 65/28 2 This is a numeric field. Department ID Code. Must be “20”.42 70/28 9 This is a dollar amount field. This is the amount from Line 20 (Income tax paid to

another state or Canadian province based on modified adjusted gross income from Line 9 above .)

43 65/30 2 This is a numeric field. Department ID Code. Must be “21”.44 70/30 9 This is a dollar amount field. This is the amount from Line 21 (VT CREDIT for income

tax paid to another state or Canadian province .) Enter the lesser of Line 19 or Line 20 . Enter this amount on Form IN-111, Line 23 (Form IN-111, Field #73)


[Page 61]

IN-119 Page

61

IN-119 Page

61

ID #

DRAFT 21 NOV 2012


For credits earned through an S-Corporation, LLC, LLP, or Partnership, enter name and FEIN of the entity. Name of entity FEIN

Ifcreditsfrommorethanonebusinessentity,filloutaseparateIN-119foreachentity.

Schedule IN-119

2012 VT Tax Credits Schedule IN-119 ATTACH TO FORM IN-111


5 6

43

21

8

9 10

7

11 12

13 14

15 16

17 18

19 20

21 22

23 24

25 26

27 28

29 30

31 32

33 34

35 36

37 38

39 40

41

59 60

61 62

63 64

65 66

67

69

71

73

68

70

72

74

75 76

77 78

79 80

81

83

82

84

43 44

45 46

47

49

51

53

55

57

48

50

52

54

56

58

85 86

87 88

89 90

91 92

93 94

95 96

97 98

99 100

101 102

103 104

105 106

107 108

109 110

111 112

113 114

115 116

117 118

119 120

121 122

123 124

125 126

127 128

42

*121193199** 1 2 1 1 9 3 1 9 9 *

[Page 62]

IN-119 Page

62

IN-119 Page

62





NOTE: If credits were earned through more than one S-Corporation, LLC, LLP, or Partnership: (1) Fill out a separate Schedule IN-119, Lines 1-22 for each entity; (2) Fill out Lines 23-44 only once and enter zero (“0”) for the remaining IN-119s, Lines 23-44; and, (3) Use the total amount from all IN-119s when Lines 23-44 ask for an amount from Lines 1-22 . Example: Line 27 requests the amount from Line 10 . Use the total amount from all IN-119s, Line 10 .



#25).3 7/21 4 This is an alpha field. Department ID Code. Must be “FEIN” .4 14/21 9 This is a numeric field. Federal EIN of entity if credits were earned through an S-Corporation,

LLC, LLP, or Partnership . Must be 9 digits . If credits were NOT earned through an S-Corporation, LLC, LLP, or Partnership, leave this field blank.

5 7/23 2 This is an alpha/numeric field. Department ID Code. Must be “1A” .6 17/23 6 This is a dollar amount field. This is the amount from Line 1, Column A (Affordable Housing

Earned in 2012) . This credit requires prior approval from VT Housing Finance Agency.7 7/25 2 This is an alpha/numeric field. Department ID Code. Must be “2A” .8 17/25 6 This is a dollar amount field. This is the amount from Line 2, Column A (Rehabilitation of

Certified Historic Buildings Earned in 2012). This credit requires prior approval from VT Division for Historic Preservation.

9 7/27 2 This is an alpha/numeric field. Department ID Code. Must be “3A” .10 17/27 6 This is a dollar amount field. This is the amount from Line 3, Column A (Older or Historic

Buildings Rehabilitation Earned in 2012) . This credit requires prior approval from VT Division for Historic Preservation.

11 7/29 2 This is an alpha/numeric field. Department ID Code. Must be “4A” .12 17/29 6 This is a dollar amount field. This is the amount from Line 4, Column A (Commercial Building

Code Improvements Earned in 2012) . This credit requires prior approval from VT Division for Historic Preservation.

13 7/31 2 This is an alpha/numeric field. Department ID Code. Must be “5A” .14 17/31 6 This is a dollar amount field. This is the amount from Line 5, Column A (Platform Lifts,

Elevators, and Sprinkler Systems Earned in 2012) . This credit requires prior approval from VT Division for Historic Preservation.

15 7/33 2 This is an alpha/numeric field. Department ID Code. Must be “6A” .16 17/33 6 This is a dollar amount field. This is the amount from Line 6, Column A (Historic Rehabilitation

Earned in 2012) . This credit requires prior approval from VT Division for Historic Preservation.

17 7/35 2 This is an alpha/numeric field. Department ID Code. Must be “7A” .

[Page 63]

IN-119 Page

63

IN-119 Page

63

DRAFT 21 NOV 201218 17/35 6 This is a dollar amount field. This is the amount from Line 7, Column A (Facade Improvement


19 7/37 2 This is an alpha/numeric field. Department ID Code. Must be “8A” .20 17/37 6 This is a dollar amount field. This is the amount from Line 8, Column A (Code Improvements


21 7/39 2 This is an alpha/numeric field. Department ID Code. Must be “9A” .22 17/39 6 This is a dollar amount field. This is the amount from Line 9, Column A (Wood Products

Manufacture Earned in 2012) .23 7/41 2 This is an alpha/numeric field. Department ID Code. Must be “1B” .24 17/41 6 This is a dollar amount field. This is the amount from Line 1, Column B (Affordable Housing

Carryforward) .25 7/43 2 This is an alpha/numeric field. Department ID Code. Must be “2B” .26 17/43 6 This is a dollar amount field. This is the amount from Line 2, Column B (Rehabilitation of

Certified Historic Buildings Carryforward).27 7/45 2 This is an alpha/numeric field. Department ID Code. Must be “3B” .28 17/45 6 This is a dollar amount field. This is the amount from Line 3, Column B (Older or Historic

Buildings Rehabilitation Carryforward) .29 7/47 2 This is an alpha/numeric field. Department ID Code. Must be “4B” .30 17/47 6 This is a dollar amount field. This is the amount from Line 4, Column B (Commercial Building

Code Improvements Carryforward) .31 7/49 2 This is an alpha/numeric field. Department ID Code. Must be “5B” .32 17/49 6 This is a dollar amount field. This is the amount from Line 5, Column B (Platform Lifts,

Elevators, and Sprinkler Systems Carryforward) .33 7/51 2 This is an alpha/numeric field. Department ID Code. Must be “6B” .34 17/51 6 This is a dollar amount field. This is the amount from Line 6, Column B (Historic Rehabilitation

Carryforward) .35 7/53 2 This is an alpha/numeric field. Department ID Code. Must be “7B” .36 17/53 6 This is a dollar amount field. This is the amount from Line 7, Column B (Facade Improvement

Carryforward) .37 7/55 2 This is an alpha/numeric field. Department ID Code. Must be “8B” .38 17/55 6 This is a dollar amount field. This is the amount from Line 8, Column B (Code Improvements

Carryforward) .39 7/57 2 This is an alpha/numeric field. Department ID Code. Must be “9B” .40 17/57 6 This is a dollar amount field. This is the amount from Line 9, Column B (Wood Products

Manufacture Carryforward) .41 7/59 2 This is an alpha/numeric field. Department ID Code. Must be “1C” .42 17/59 6 This is a dollar amount field. This is the amount from Line 1, Column C (Affordable Housing

2012 Credit) . Add Lines 1A and 1B (Fields #6 & #24).43 38/19 2 This is an alpha/numeric field. Department ID Code. Must be “2C” .44 44/19 6 This is a dollar amount field. This is the amount from Line 2, Column C (Rehabilitation of

Certified Historic Buildings 2012 Credit). Add Lines 2A and 2B (Fields #8 & #26).45 38/21 2 This is an alpha/numeric field. Department ID Code. Must be “3C” .46 44/21 6 This is a dollar amount field. This is the amount from Line 3, Column C (Older or Historic

Buildings Rehabilitation 2012 Credit) . Add Lines 3A and 3B (Fields #10 & #28).47 38/23 2 This is an alpha/numeric field. Department ID Code. Must be “4C” .48 44/23 6 This is a dollar amount field. This is the amount from Line 4, Column C (Commercial Building

Code Improvements 2012 Credit) . Add Lines 4A and 4B (Fields #12 & #30).49 38/25 2 This is an alpha/numeric field. Department ID Code. Must be “5C” .50 44/25 6 This is a dollar amount field. This is the amount from Line 5, Column C (Platform Lifts,

Elevators, and Sprinkler Systems 2012 Credit) . Add Lines 5A and 5B (Fields #14 & #32).51 38/27 2 This is an alpha/numeric field. Department ID Code. Must be “6C” .

[Page 64]

IN-119 Page

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IN-119 Page

64

DRAFT 21 NOV 201252 44/27 6 This is a dollar amount field. This is the amount from Line 6, Column C (Historic Rehabilitation

2012 Credit) . Add Lines 6A and 6B (Fields #16 & #34).53 38/29 2 This is an alpha/numeric field. Department ID Code. Must be “7C” .54 44/29 6 This is a dollar amount field. This is the amount from Line 7, Column C (Facade Improvement

2012 Credit) . Add Lines 7A and 7B (Fields #18 & #36).55 38/31 2 This is an alpha/numeric field. Department ID Code. Must be “8C” .56 44/31 6 This is a dollar amount field. This is the amount from Line 8, Column C (Code Improvements

2012 Credit) . Add Lines 8A and 8B (Fields #20 & #38).57 38/33 2 This is an alpha/numeric field. Department ID Code. Must be “9C” .58 44/33 6 This is a dollar amount field. This is the amount from Line 9, Column C (Wood Products

Manufacture 2012 Credit) . Add Lines 9A and 9B (Fields #22 & #40).59 38/35 2 This is a numeric field. Department ID Code. Must be “10” .60 44/35 6 This is a dollar amount field. This is the amount from Line 10 (Add Column C, Lines 1-9).61 38/37 2 This is a numeric field. Department ID Code. Must be “11” .62 44/37 6 This is a dollar amount field. This is the amount from Line 11. Use the amount from

Schedule IN-112, Part IV, Line 7 (Schedule IN-112, Field #106).63 38/39 2 This is a numeric field. Department ID Code. Must be “12” .64 44/39 6 This is a dollar amount field. This is the amount from Line 12 (Add Lines 10 & 11). If there

are no entries on Lines 13-21 (Fields #66 - #82, even-numbered fields), enter this amount on Form IN-111, Line 24 (Form IN-111, Field #75).

65 38/41 2 This is a numeric field. Department ID Code. Must be “13” .66 44/41 6 This is a dollar amount field. This is the amount from Line 13 (VT Entrepreneur’s Seed Capital

Fund) .67 38/43 2 This is a numeric field. Department ID Code. Must be “14” .68 44/43 6 This is a dollar amount field. This is the amount from Line 14 (Payroll 2012 Credit). 69 38/45 2 This is a numeric field. Department ID Code. Must be “15” .70 44/45 6 This is a dollar amount field. This is the amount from Line 15 (Research & Development 2012

Credit) . 71 38/47 2 This is a numeric field. Department ID Code. Must be “16” .72 44/47 6 This is a dollar amount field. This is the amount from Line 16 (Capital Investment 2012 Credit). 73 38/49 2 This is a numeric field. Department ID Code. Must be “17” .74 44/49 6 This is a dollar amount field. This is the amount from Line 17 (Workforce Development 2012

Credit) . 75 38/51 2 This is a numeric field. Department ID Code. Must be “18” .76 44/51 6 This is a dollar amount field. This is the amount from Line 18 (Export 2012 Credit). 77 38/53 2 This is a numeric field. Department ID Code. Must be “19” .78 44/53 6 This is a dollar amount field. This is the amount from Line 19 (High-Tech Growth 2012 Credit). 79 38/55 2 This is a numeric field. Department ID Code. Must be “20” .80 44/55 6 This is a dollar amount field. This is the amount from Line 20 (Sustainable Technology R & D

2012 Credit) . 81 38/57 2 This is a numeric field. Department ID Code. Must be “21” .82 44/57 6 This is a dollar amount field. This is the amount from Line 21 (Sustainable Technology Export

2012 Credit) . 83 38/59 2 This is a numeric field. Department ID Code. Must be “22” .84 44/59 6 This is a dollar amount field. This is the amount from Line 22 (Add Lines 14-21).85 65/19 2 This is a numeric field. Department ID Code. Must be “23” .86 70/19 9 This is a dollar amount field. This is the amount from Line 23 (Adjusted VT income tax). Use

the amount from Form IN-111, Line 22 (Form IN-111, Field #71).87 65/21 2 This is a numeric field. Department ID Code. Must be “24” .88 70/21 9 This is a dollar amount field. This is the amount from Line 24 (Credit for income tax paid to

another state or Canadian province) . Use the amount from Form IN-111, Line 23 (Form IN-111, Field #73).

89 65/23 2 This is a numeric field. Department ID Code. Must be “25” .

[Page 65]

IN-119 Page

65

IN-119 Page

65

DRAFT 21 NOV 201290 70/23 9 This is a dollar amount field. This is the amount from Line 25. Subtract Line 24 (Field #88)

from Line 23 (Field #86).91 65/25 2 This is a numeric field. Department ID Code. Must be “26” .92 70/25 9 This is a dollar amount field. This is the amount from Line 26 (Amount from Line 11). Use

the amount from Schedule IN-119, Line 11 (IN-119, Field #62).93 65/27 2 This is a numeric field. Department ID Code. Must be “27” .94 70/27 9 This is a dollar amount field. This is the amount from Line 27. Enter the amount from

Schedule IN-119, Line 10 (Field #60).95 65/29 2 This is a numeric field. Department ID Code. Must be “28” .96 70/29 9 This is a dollar amount field. This is the amount from Line 28. Add Lines 26 and 27 (Fields

#92 and #94).97 65/31 2 This is a numeric field. Department ID Code. Must be “29” .98 70/31 9 This is a dollar amount field. This is the amount from Line 29. Enter the smaller of Line 25

(Field #90) or Line 28 (Field #96).99 65/33 2 This is a numeric field. Department ID Code. Must be “30” .100 70/33 9 This is a dollar amount field. This is the amount from Line 30. Subtract Line 29 (Field #98)

from Line 25 (Field #90). If this amount is negative, enter “0”.101 65/35 2 This is a numeric field. Department ID Code. Must be “31” .102 70/35 9 This is a dollar amount field. This is the amount from Line 31. Multiply Line 30 (Field #100)

by 50%.103 65/37 2 This is a numeric field. Department ID Code. Must be “32” .104 70/37 9 This is a dollar amount field. This is the amount from Line 32 (Amount from Line 13). Use

the amount from Schedule IN-119, Line 13 (Field #66).105 65/39 2 This is a numeric field. Department ID Code. Must be “33” .106 70/39 9 This is a dollar amount field. This is the amount from Line 33. Enter the smaller of Line 31

(Field #102) or Line 32 (Field #104).107 65/41 2 This is a numeric field. Department ID Code. Must be “34” .108 70/41 9 This is a dollar amount field. This is the amount from Line 34. Subtract Line 33 (Field #106)

from Line 30 (Field #100). If this amount is negative, enter “0”.

Complete Lines 35 - 42 (Fields #110 - #124, even-numbered fields) if taxpayer is claiming Economic Advancement Tax Incentive (EATI) Credit. Otherwise, enter “0” in Fields #110 - #124 and go to Line 43 (Field #126).

109 65/43 2 This is a numeric field. Department ID Code. Must be “35” .110 70/43 9 This is a dollar amount field. This is the amount from Line 35 (VT tax from Form IN-111, Line

22) . Use the amount from Form IN-111, Line 22 (IN-111, Field #71).111 65/45 2 This is a numeric field. Department ID Code. Must be “36” .112 70/45 9 This is a dollar amount field. This is the amount from Line 36 [Schedule K-1 income from

entity with EATI credit(s)] . If this amount is negative, enter “0” here and on Line 38 (Field #116).

113 65/47 2 This is a numeric field. Department ID Code. Must be “37” .114 70/47 9 This is a dollar amount field. This is the amount from Line 37 (Adjusted Gross Income).

Residents: Use the amount from Form IN-111, Line 10 (Form IN-111, Field #37); Nonresidents: Use the amount from Schedule IN-113, Line 42 (Schedule IN-113, Field #148). If this amount is negative, enter “0” here and on Line 38 (Field #116).

115 65/49 2 This is a numeric field. Department ID Code. Must be “38” .116 74/49 5 This is a numeric (percentage) field. This is the amount from Line 38. Divide Line 36 (Field

#112) by Line 37 (Field #114). Cannot be less than 0.00% or greater than 100.00%.117 65/51 2 This is a numeric field. Department ID Code. Must be “39” .118 70/51 9 This is a dollar amount field. This is the amount from Line 39 (VT Tax attributable to Schedule

K-1 Income) . Multiply Line 35 (Field #110) by Line 38 (Field #116).119 65/53 2 This is a numeric field. Department ID Code. Must be “40” .120 70/53 9 This is a dollar amount field. This is the amount from Line 40 (Statutory Credit Limitation).

Multiply Line 39 (Field #118) by 80%.

[Page 66]

IN-119 Page

66

IN-119 Page

66

DRAFT 21 NOV 2012121 65/55 2 This is a numeric field. Department ID Code. Must be “41” .122 70/55 9 This is a dollar amount field. This is the amount from Line 41 (Credit Claimed). Use the

amount from Line 22 (Field #84). If multiple IN-119s are filed, use the total amount from all IN-119s, Line 22.

123 65/57 2 This is a numeric field. Department ID Code. Must be “42” .124 70/57 9 This is a dollar amount field. This is the amount from Line 42 (Maximum allowable EATI

Credit) . Enter the smaller of Line 40 (Field #120) or Line 41 (Field #122) .125 65/59 2 This is a numeric field. Department ID Code. Must be “43” .126 70/59 9 This is a dollar amount field. This is the amount from Line 43 (Total Credits Allowable). Enter

the total of Lines 29, 33, and 42 (Fields #98, #106, and #124) .127 65/61 2 This is a numeric field. Department ID Code. Must be “44” .128 70/61 9 This is a dollar amount field. This is the amount from Line 44 (Total Income Tax Credits

Available) . Enter the smaller of Line 25 (Field #90) or Line 43 (Field #126) . Enter this amount on Form IN-111, Line 24 (Form IN-111, Field #75).


[Page 67]

HS-122 Page

67

HS-122 Page

67

ID #

DRAFT 21 NOV 20122013 VT Homestead Declaration AND Property Tax Adjustment Claim Form HS-122

DUE DATE: April 15, 2013(ClaimsalloweduptoOctober15,2013butlatefilingpenaltiesapply)This form can be filed on-line at http://tax.vermont.gov

Check here if authorizing the VT Department of Taxes to discuss this return and attachments with your preparer.

Form HS-122



Location of Homestead (number, street/road name DO NOT use PO Box, “same”, or Town name) 3. SPAN Number (REQUIRED)

(From your property tax bill)


Claimant’sSSN

Spouse or CUPartner SSNClaimant’s Date of Birth

Homeowner signature Date Preparer’s signature Date Print Firm’s name (or yours if self-employed) and address below

If a joint return, Spouse or CU Partner must sign Date Taxpayer’s Telephone Number Spouse or CU Partner Telephone Number Preparer’s Telephone Number


27

29

40

42

44

46

48

50

52

30 31

55

57

59

61

63

65

67

26

28

41

43

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[Page 68]

HS-122 Page

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HS-122 Page

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DRAFT 21 NOV 20122013 HS-122, Page 1 Specifications





1 7/22 2 This is an alpha field. Department ID Code. Must be “TY” .2 12/22 4 This is a numeric field. This is the Tax Year. Must be “2013” .3 26/22 3 This is an alpha field. Department ID Code. Must be “DSC” .4 32/22 1 This is an alpha field. This is the answer to the check-box authorizing the Department to discuss

return with preparer . Must be “Y” or “N” .5 43/22 3 This is an alpha field. Department ID Code. Must be “DOB” .6 49/22 8 This is a numeric field. Claimant’s Date of Birth. Must be 8 digits (MMDDYYYY) . This is

a REQUIRED ENTRY .7 7/24 20 This is an alpha field. Claimant’s Last Name. This is a REQUIRED ENTRY .8 31/24 20 This is an alpha field. Claimant’s First Name. This is a REQUIRED ENTRY .9 55/24 1 This is an alpha field. Claimant’s Middle Initial.10 60/24 9 This is a numeric field. Claimant’s Social Security Number. Must be 9 digits. This is a





if there is no Spouse or CU Partner, leave this field blank.15 7/28 35 This is an alpha/numeric field. Mailing Address.16 7/30 25 This is an alpha field. City or Town for mailing address.17 36/30 2 This is an alpha field. State for mailing address. Use the standard 2-character state abbreviation.18 43/30 9 This is a numeric field. ZIP Code for mailing address. Must have 5 or 9 digits only. DO NOT

enter a hyphen (-) or space between the 5-digit ZIP Code and the “+4” digits.19 7/32 3 This is a numeric field. This is the VT School District Code for legal residence on April 1, 2013.

MUST be 3 digits . Example: “003”, not “3” . Must be “001” - “262” for residents or “999” for nonresidents . If “999”, do not file this form. This is a REQUIRED ENTRY . Fields #19 & #20 must identify the same town .

20 13/32 25 This is an alpha field. City or Town of Legal Residence on April 1, 2013. This is a REQUIRED ENTRY . This may be different than City or Town used for mailing purposes . Fields #19 & #20 must identify the same town .

21 42/32 2 This is an alpha field. State of Legal Residence on April 1, 2013. This is a REQUIRED ENTRY . This may be different than State used for mailing purposes . Use the standard 2-character state abbreviation . If State is anything other than “VT”, do not file this form.

22 55/32 4 This is an alpha field. Department ID Code. Must be “SPAN” .

[Page 69]

HS-122 Page

69

HS-122 Page

69

DRAFT 21 NOV 201223 62/32 11 This is a numeric field. This is the SPAN Number (School Property Account Number - from

property tax bill) . Must be 11 digits . This is a REQUIRED ENTRY .24 7/34 3 This is an alpha field. Department ID Code. Must be “LOC” .25 13/34 35 This is an alpha/numeric field. This is the Location of Homestead. This is the PHYSICAL

STREET ADDRESS, including house number, of the homestead (City is listed in “City/Town of Legal Residence . . .”) . This may be different than the mailing address . This is a REQUIRED ENTRY . A PO Box, “same”, or Town name are unacceptable entries for the Location of Homestead.

26 7/36 2 This is an alpha/numeric field. Department ID Code. Must be “A4” .27 12/36 5 This is a numeric (percentage) field. This is the percentage from Line A4 (Business Use of

Dwelling) . Round percentage to nearest whole percentage. Show two places (“00”) to the right of the implied decimal point in the scanband. If no business use OR BUSINESS USE IS LESS THAN 26.00%, enter “0”. (More than 25.00% business use requires adjustment.) If business use is 100.00%, DO NOT FILE THIS FORM.

28 7/38 2 This is an alpha/numeric field. Department ID Code. Must be “A5” .29 12/38 5 This is a numeric (percentage) field. This is the percentage from Line A5 (Rental Use of

Dwelling) . Round percentage to nearest whole percentage. Show two places (“00”) to the right of the implied decimal point in the scanband. If no rental use, enter “0”. If rental use is 100.00%, DO NOT FILE THIS FORM.

30 7/40 2 This is an alpha/numeric field. Department ID Code. Must be “A6” . 31 16/40 1 This is an alpha field. This is the answer to Line A6 - “Not including the dwelling, are

improvements or other buildings located on your parcel used for business or rented?” Must be “Y” or “N” .

32 7/42 2 This is an alpha/numeric field. Department ID Code. Must be “A7” . 33 16/42 1 This is an alpha field. This is the answer to Line A7 - SPECIAL SITUATIONS - Are you

grantor and sole beneficiary of a revocable trust owning the property? Must be “Y” or “N” .34 7/44 2 This is an alpha/numeric field. Department ID Code. Must be “A8” . 35 16/44 1 This is an alpha field. This is the answer to Line A8 - SPECIAL SITUATIONS - Are you life

estate holder of the property? Must be “Y” or “N” .36 7/46 2 This is an alpha/numeric field. Department ID Code. Must be “A9” . 37 16/46 1 This is an alpha field. This is the answer to Line A9 - SPECIAL SITUATIONS - Does your

homestead cross town boundaries? Must be “Y” or “N” . If “Y”, you must file a declaration for each town.

38 7/48 3 This is an alpha/numeric field. Department ID Code. Must be “A10” . 39 16/48 1 This is an alpha field. This is the answer to Line A10 - SPECIAL SITUATIONS - Are you

residing in a dwelling owned by a related farmer? Must be “Y” or “N” .40 25/36 2 This is an alpha/numeric field. Department ID Code. Must be “B1” .41 36/36 1 This is an alpha field. This is the answer to Line B1, “Were you domiciled in VT all of calendar

year 2012?” . Must be “Y” or “N” . If “N”, do not file this form.42 25/38 2 This is an alpha/numeric field. Department ID Code. Must be “B2” .43 36/38 1 This is an alpha field. This is the answer to Line B2, “Were you claimed as a dependent in

2012 by another taxpayer?” . Must be “Y” or “N” . If “Y”, do not file this form.44 25/40 2 This is an alpha/numeric field. Department ID Code. Must be “B3” .45 36/40 1 This is an alpha field. This is the answer to Line B3, “Do you anticipate selling your VT

housesite on or before April 1, 2013?” . Must be “Y” or “N” . If “N”, do not file this form.46 25/42 2 This is an alpha/numeric field. Department ID Code. Must be “B4” . 47 30/42 7 This is a dollar amount field. This is the amount from Line B4 (Housesite Value).48 25/44 2 This is an alpha/numeric field. Department ID Code. Must be “B5” . 49 32/44 5 This is a dollar amount field. This is the amount from Line B5 (Housesite Education Tax).50 25/46 2 This is an alpha/numeric field. Department ID Code. Must be “B6” . 51 32/46 5 This is a dollar amount field. This is the amount from Line B6 (Housesite Municipal Tax).52 25/48 2 This is an alpha/numeric field. Department ID Code. Must be “B7” .53 32/48 5 This is a numeric (percentage) field. This is the percentage from Line B7 (Ownership Interest).

Round percentage to the nearest whole percentage.

[Page 70]

HS-122 Page

70

HS-122 Page

70

DRAFT 21 NOV 201254 45/36 2 This is an alpha/numeric field. Department ID Code. Must be “B8” .55 50/36 6 This is a dollar amount field. This is the amount from Line B8 (Household Income). Use the

amount from Schedule HI-144, Line y (HI-144, Field #170). NOTE: This is not the same as AGI. If Household Income is MORE THAN $999,000, Claimant is not eligible for a Property Tax Adjustment.

56 45/38 3 This is an alpha/numeric field. Department ID Code. Must be “B8a” . 57 55/38 1 This is an alpha field. This is the answer to Line B8a (Is AMENDED SCHEDULE HI-144,

Household Income, attached?) . Must be “Y” or “N” .

NOTE FOR LINES B9 - B13: If applicable, complete Line B9 OR Lines B10-B11 OR Lines B12-B-13. Enter default data (“0”) for unused lines.

58 45/40 2 This is an alpha/numeric field. Department ID Code. Must be “B9” . 59 51/40 5 This is a dollar amount field. This is the amount from Line B9 (Mobile Home Lot Rent from

Form LC-142, Line 16) . If there is an amount on this line, enter “0” for Lines B10-B13 (Fields #61, #63, #65, and #67).

60 45/42 3 This is an alpha/numeric field. Department ID Code. Must be “B10” . 61 51/42 5 This is a dollar amount field. This is the amount from Line B10 (Allocated Education Tax

from Land Trust, Cooperative, or Nonprofit Mobile Home Park). If there is an amount on this line, enter “0” on Lines B9, B12, and B13 (Fields #59, #65, and #67). Also, if there is an amount on this line, there should also be an amount on Line B11 (Field #63).

62 45/44 3 This is an alpha/numeric field. Department ID Code. Must be “B11” . 63 51/44 5 This is a dollar amount field. This is the amount from Line B11 (Allocated Municipal Tax

from Land Trust, Cooperative, or Nonprofit Mobile Home Park). If there is an amount on this line, enter “0” on Lines B9, B12, and B13 (Fields #59, #65, and #67). Also, if there is an amount on this line, there should also be an amount on Line B10 (Field #61).

64 45/46 3 This is an alpha/numeric field. Department ID Code. Must be “B12” . 65 51/46 5 This is a dollar amount field. This is the amount from Line B12 (Education Tax on contiguous

property if housesite has less than 2 acres) . If there is an amount on this line, enter “0” on Lines B9, B10, and B11 (Fields #59, #61, and #63). Also, if there is an amount on this line, there should also be an amount on Line B13 (Field #67).

66 45/48 3 This is an alpha/numeric field. Department ID Code. Must be “B13” . 67 51/48 5 This is a dollar amount field. This is the amount from Line B13 (Municipal Tax on contiguous

property if housesite has less than 2 acres) . If there is an amount on this line, enter “0” on Lines B9, B10, and B11 (Fields #59, #61, and #63) Also, if there is an amount on this line, there should also be an amount on Line B12 (Field #65).

68 64/36 4 This is an alpha field. Department ID Code. Must be “PTIN” .69 71/36 9 This is an alpha/numeric field. Preparer’s Social Security Number or PTIN. Must be 9 characters.


prepared, leave this field blank.


[Page 71]

PR-141 Page

71

PR-141 Page

71

ID #

DRAFT 21 NOV 20122012 VT Renter Rebate Claim Form PR-141 FOR HOUSEHOLD INCOME OF $47,000 OR LESSFor the year Jan. 1 - Dec. 31, 2012DUE DATE: April 15, 2013 (Claims allowed up to Oct. 15, 2013)

Form PR-141


Check here if authorizing the Vermont Department of Taxes to discuss this return and attachments with your preparer.

REBATE CALCULATION. Before doing rebate calculation, complete Household Income (Schedule HI-144).3. ALLOCABLE RENT (LC-142, Line 16) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4. HOME USE. If more than 25% of this rental is used for business, see instructions. If not, enter 100.00%. 4. %5. ALLOWABLE RENT FOR REBATE CLAIM (Multiply Line 3 by Line 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.6. HOUSEHOLD INCOME (From Schedule HI-144, Line y) If more than $47,000, you are not eligible. . . . . . 6. 6a. If AMENDED SCHEDULE HI-144, Household Income, is attached, check here. . 7. MAXIMUM PERCENTAGE OF INCOME FOR RENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. % If Line 6 Household Income is: $0 - 9,999 $10,000 - 24,999 $25,000 - 47,000 Enter this % on Line 7: 2.00% 4.50% 5.00%8. MAXIMUM RENT FOR HOUSEHOLD INCOME (Multiply Line 6 by Line 7 and enter result here) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. If Line 8 is more than Line 5, you do not qualify for a renter rebate.9. RENTER REBATE AMOUNT(SubtractLine8fromLine5andenterresulthere.)Ifresultiszero,youdonotqualifyforarebate.Iffilingthis form with the VT Income Tax Return, also enter this amount on Form IN-111, Line 31d.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.

MAXIMUM REBATE AMOUNT IS $3,000. ATTACH SCHEDULE HI-144 AND LC-142.

Claimant’s SSN


Claimant’sDate of Birth




Your signature Date Preparer’s signature Date Print Firm’s name (or yours if self-employed) and address below

Spouse or CU Partner signature. If a joint return, BOTH must sign. Date Claimant’s Telephone Number Spouse or CU Partner Telephone Number Preparer’s Telephone Number

MAIL TO: Vermont Department of Taxes, PO Box 1881, Montpelier, VT 05601-1881

Must Be Filed With: Household Income (Schedule HI-144) and Landlord’s Certificate (LC-142)

Location of rental property (number, street/road name DO NOT use PO Box, “same”, or Town name)ALL eligibility questions must be answered. You must have rented all 12 months in 2012. See instructions for exception.Q1. Were you domiciled in VT all of calendar year 2012? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes, Go to Q2. No, STOP. You are not eligible.Q2. Were you claimed as a dependent by another taxpayer in 2012? . . . . . . . . . . . . . . . . . . . . Yes, STOP. You are not eligible. No, Go to Q3.Q3. Did you rent in VT all 12 months in calendar year 2012? . . . . . . . . . . . . . . . . . . . . . . . . . . Yes, Complete this form. No, STOP. You are not eligible.

1 2 4

32 33

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24 25

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42 44 45 46 47 48 4943

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[Page 72]

PR-141 Page

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PR-141 Page

72

DRAFT 21 NOV 20122012 PR-141, Page 1 Specifications





1 7/23 2 This is an alpha field. Department ID Code. Must be “TY” .2 12/23 4 This is a numeric field. This is the Tax Year. Must be 4 digits. Must be “2012” .3 22/23 3 This is an alpha field. Department ID Code. Must be “DSC” .4 28/23 1 This is an alpha field. This is the answer to the check-box authorizing the Department to discuss

return with preparer . Must be “Y” or “N” .5 35/23 3 This is an alpha field. Department ID Code. Must be “DOB” .6 41/23 8 This is a numeric field. Claimant’s Date of Birth. Must be 8 digits (MMDDYYYY) . This is

a REQUIRED ENTRY .7 60/23 2 This is an alpha/numeric field. Department ID Code. Must be “6a” .8 65/23 1 This is an alpha field. This is the answer to “If AMENDED SCHEDULE HI-144, Household

Income, is attached, check here .” (Line 6a) Must be “Y” (box is checked) or “N” (leave box blank) .

9 7/25 20 This is an alpha field. Claimant’s Last Name. This is a REQUIRED ENTRY .10 31/25 20 This is an alpha field. Claimant’s First Name. This is a REQUIRED ENTRY .11 55/25 1 This is an alpha field. Claimant’s Middle Initial.12 60/25 9 This is a numeric field. Claimant’s Social Security Number. Must be 9 digits. This is a





if there is no Spouse or CU Partner, leave this field blank.17 7/29 35 This is an alpha/numeric field. Mailing Address. 18 46/29 25 This is an alpha field. City or Town for mailing address.19 75/29 2 This is an alpha field. State for mailing address. Use the standard 2-character state abbreviation.20 7/31 9 This is a numeric field. ZIP Code for mailing address. Must have 5 or 9 digits only. DO NOT

enter a hyphen (-) or space between the 5-digit ZIP Code and the “+4” digits.21 20/31 3 This is a numeric field. This is the VT School District Code. This is a REQUIRED ENTRY .

MUST be 3 digits . Example: “003”, not “3” . Must be “001” - “262” for residents or “999” for nonresidents . If “999”, do not file this form. Fields #21 and #22 must identify the same town . This may be different than the town used in the mailing address .

22 27/31 25 This is an alpha field. City or Town of Legal Residence on December 31, 2012. This is a REQUIRED ENTRY . Fields #21 and #22 must identify the same town . This may be different than the town used in the mailing address .

[Page 73]

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PR-141 Page

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DRAFT 21 NOV 201223 56/31 2 This is an alpha field. State of Legal Residence on December 31, 2012. This is a REQUIRED

ENTRY . This may be different than State used for mailing purposes . Use the standard 2-character state abbreviation .

24 7/33 3 This is an alpha field. Department ID Code. Must be “LOC” .25 13/33 21 This is an alpha/numeric field. This is the Location of Rental Property. This is the PHYSICAL

STREET address, including house number, and apartment number if applicable, of the rental property (City is listed in “City/Town of Legal Residence...”). This may be different from the mailing address. This is a REQUIRED ENTRY . A PO Box, “same”, or Town name is NOT an acceptable entry for the Location of Rental Property.

26 42/33 2 This is an alpha/numeric field. Department ID Code. Must be “Q1” .27 47/33 1 This is an alpha field. This is the answer to Q1, “Were you domiciled in VT all of calendar

year 2012?” . Must be “Y” or “N” . If “N”, do not file this form.28 55/33 2 This is an alpha/numeric field. Department ID Code. Must be “Q2” .29 60/33 1 This is an alpha field. This is the answer to Q2, “Were you claimed as a dependent by another

taxpayer in 2012?” . Must be “Y” or “N” . If “Y”, do not file this form.30 68/33 2 This is an alpha/numeric field. Department ID Code. Must be “Q3” .31 73/33 1 This is an alpha field. This is the answer to Q3, “Did you rent in VT all 12 months in calendar

year 2012?” . Must be “Y” or “N” . If “N”, do not file this form.32 7/35 1 This is a numeric field. Department ID Code. Must be “3” . 33 11/35 5 This is a dollar amount field. This is the amount from Line 3 (Allocable Rent).34 21/35 1 This is a numeric field. Department ID Code. Must be “4” .35 25/35 5 This is a numeric (percentage) field. This is the percentage from Line 4 (Home Use). Round

percentage to the nearest whole percentage.36 35/35 1 This is a numeric field. Department ID Code. Must be “5” . 37 39/35 5 This is a dollar amount field. This is the amount from Line 5 (Allowable Rent for Rebate

Claim) . Multiply Line 3 (Field #33) by Line 4 (Field #35).38 49/35 1 This is a numeric field. Department ID Code. Must be “6” .39 53/35 5 This is a dollar amount field. This is the amount from Line 6 (Household Income). Use the

amount from Schedule HI-144, Line y (HI-144, Field #170). NOTE: This is not the same as AGI. If Household Income is MORE THAN $47,000, Claimant is not eligible for a Renter Rebate.

40 63/35 1 This is a numeric field. Department ID Code. Must be “7” .41 67/35 3 This is a numeric (percentage) field. This is the percentage from Line 7 (Maximum Percentage

of Income for Rent) . Must be “200”, “450”, or “500” only .42 7/37 1 This is a numeric field. Department ID Code. Must be “8” . 43 11/37 5 This is a dollar amount field. This is the amount from Line 8 (Maximum Rent for Household

Income) . Multiply Line 6 (Field #39) by Line 7 (Field #41). If Line 8 (Field #43) is more than Line 5 (Field #37), Claimant does not qualify for a renter rebate.

44 21/37 1 This is a numeric field. Department ID Code. Must be “9” .45 25/37 5 This is a dollar amount field. This is the amount from Line 9 (Renter Rebate Amount). Subtract

Line 8 (Field #43) from Line 5 (Field #37). If result is zero, Claimant does not qualify for a rebate. If filing this form with the VT Income Tax Return, enter this amount on Form IN-111, Line 31d (IN-111, Field #101). Also, if filing with Form IN-111, this form must print at the same time as Form IN-111.

46 35/37 4 This is an alpha field. Department ID Code. Must be “PTIN” .47 42/37 9 This is an alpha/numeric field. Preparer’s Social Security Number or PTIN. Must be 9 characters.


prepared, leave this field blank.


[Page 74]

HI-144 Page

74

HI-144 Page

74

ID #

DRAFT 21 NOV 20122012 VT Household Income Schedule HI-144

For the year Jan. 1 - Dec. 31, 2012This schedule must be attached to the 2012 Renter Rebate Claim (Form PR-141) OR the

2013 Property Tax Adjustment Claim (Form HS-122) UNLESS you are filing an AMENDED HI-144. Please read instructions before completing schedule.

Claimant’s Last Name First Name Initial Claimant’s Social Security Number

Claimant’s Date of Birth (MMDDYYYY)FOR COMPUTERIZED USE ONLY

Schedule HI-144

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1817

21

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131 132

52

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57

55 56

168 170

93 94 133 134

135 136

137 138

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141 142

143 144

145 146

147 148

149 150

151 152

165 166

167 168

153 154

155 156

157

159

161

163

158

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162

164

8

13

9

14

43

11

16

1210

15

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[Page 75]

HI-144 Page

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HI-144 Page

75

DRAFT 21 NOV 20122012 HI-144, Page 1 Specifications




IMPORTANT: Dollar amounts on Schedule HI-144 MUST NEVER exceed 6 digits! If any dollar amount on this schedule is MORE THAN 6 digits, taxpayer will not qualify for the programs applied for on Forms HS-122 and PR-141.


1 7/16 3 This is an alpha field. Department ID Code. Must be “SSN” .2 13/16 9 This is a numeric field. Claimant’s Social Security Number. Must be 9 digits.3 7/18 3 This is an alpha/numeric field. Department ID Code. Must be “OP1” .4 13/18 20 This is an alpha field. “Other Person #1” Last Name. If there is no “Other Person” who had

income and lived with you during 2012, leave this field blank.5 38/18 15 This is an alpha field. “Other Person #1” First Name. If there is no “Other Person” who had

income and lived with you during 2012, leave this field blank.6 57/18 1 This is an alpha field. “Other Person #1” Middle Initial. If there is no “Other Person” who

had income and lived with you during 2012, leave this field blank. 7 63/18 9 This is a numeric field. “Other Person #1” Social Security Number. Must be 9 digits. If there

is no “Other Person” who had income and lived with you during 2012, leave this field blank.

8 7/20 3 This is an alpha/numeric field. Department ID Code. Must be “OP2” .9 13/20 20 This is an alpha field. “Other Person #2” Last Name. If there is no “Other Person”, or if

there is only one “Other Person” who had income and lived with you during 2012, leave this field blank.

10 38/20 15 This is an alpha field. “Other Person #2” First Name. If there is no “Other Person”, or if there is only one “Other Person” who had income and lived with you during 2012, leave this field blank.

11 57/20 1 This is an alpha field. “Other Person #2” Middle Initial. If there is no “Other Person”, or if there is only one “Other Person” who had income and lived with you during 2012, leave this field blank.

12 63/20 9 This is a numeric field. “Other Person #2” Social Security Number. Must be 9 digits. If there is no “Other Person”, or if there is only one “Other Person” who had income and lived with you during 2012, leave this field blank.

13 7/22 3 This is an alpha field. Department ID Code. Must be “SPD” .14 13/22 20 This is an alpha field. Name of person receiving support (see Line p). Preferred format of

name is Last Name then First Name . No spaces or commas in between . If there is no person receiving child support (Lines 1p, 2p AND 3p are “0”), leave this field blank.

15 38/22 6 This is an alpha field. Department ID Code. Must be “SPDSSN” .16 47/22 9 This is a numeric field. Social Security Number of person receiving support (see Line p). Must

be 9 digits . If there is no person receiving child support (Lines 1p, 2p AND 3p are “0”), leave this field blank.

17 7/24 2 This is an alpha/numeric field. Department ID Code. Must be “1a” .

[Page 76]

HI-144 Page

76

HI-144 Page

76

DRAFT 21 NOV 201218 13/24 6 This is a dollar amount field. Amount from Line 1a (Claimant Cash public assistance and

relief) .19 7/26 2 This is an alpha/numeric field. Department ID Code. Must be “1b” .20 13/26 6 This is a dollar amount field. Amount from Line 1b (Claimant Social security, railroad retirement,

veteran’s benefits, taxable and nontaxable) .21 7/28 2 This is an alpha/numeric field. Department ID Code. Must be “1c” .22 13/28 6 This is a dollar amount field. Amount from Line 1c (Claimant Unemployment compensation/

worker’s compensation) .23 7/30 2 This is an alpha/numeric field. Department ID Code. Must be “1d” .24 13/30 6 This is a dollar amount field. Amount from Line 1d (Claimant Wages, salaries, tips, etc.) See

instructions for dependent’s exempt income .25 7/32 2 This is an alpha/numeric field. Department ID Code. Must be “1e” .26 13/32 6 This is a dollar amount field. Amount from Line 1e (Claimant Interest and dividends).27 7/34 2 This is an alpha/numeric field. Department ID Code. Must be “1f” .28 13/34 6 This is a dollar amount field. Amount from Line 1f (Claimant Interest on U. S., state, and

municipal obligations, taxable and nontaxable) .29 7/36 2 This is an alpha/numeric field. Department ID Code. Must be “1g” .30 13/36 6 This is a dollar amount field. Amount from Line 1g (Claimant Alimony, support money, child

support, cash gifts) .31 7/38 2 This is an alpha/numeric field. Department ID Code. Must be “1h” .32 13/38 6 This is a dollar amount field. Amount from Line 1h (Claimant Business income). If the amount

is a loss, enter zero. See instructions for offsetting a loss.33 7/40 2 This is an alpha/numeric field. Department ID Code. Must be “1i” .34 13/40 6 This is a dollar amount field. Amount from Line 1i (Claimant Capital gains, taxable and

nontaxable) . If the amount is a loss, enter zero. See instructions for offsetting a loss.35 7/42 2 This is an alpha/numeric field. Department ID Code. Must be “1j” .36 13/42 6 This is a dollar amount field. Amount from Line 1j (Claimant Taxable pensions, annuities,

IRA and other retirement fund distributions) . (See instructions.)37 7/44 2 This is an alpha/numeric field. Department ID Code. Must be “1k” .38 13/44 6 This is a dollar amount field. Amount from Line 1k (Claimant Rental and royalty income). If

the amount is a loss, enter zero. See instructions for offsetting a loss.39 7/46 2 This is an alpha/numeric field. Department ID Code. Must be “1l” .40 13/46 6 This is a dollar amount field. Amount from Line 1l (Claimant Farm/partnerships/S Corporations/

LLC/Estate or Trust income) . If the amount is a loss, enter zero. See instructions for offsetting a loss.

41 7/48 2 This is an alpha/numeric field. Department ID Code. Must be “1m” .42 13/48 6 This is a dollar amount field. Amount from Line 1m (Claimant Other income). Print source

of Other income on Page 2 of this schedule .43 7/50 2 This is an alpha/numeric field. Department ID Code. Must be “1n” .44 13/50 6 This is a dollar amount field. Amount from Line 1n (Claimant TOTAL INCOME). Add Lines

1a through 1m .45 7/52 2 This is an alpha/numeric field. Department ID Code. Must be “2a” .46 13/52 6 This is a dollar amount field. Amount from Line 2a (Spouse or CU Partner Cash public assistance

and relief) .47 7/54 2 This is an alpha/numeric field. Department ID Code. Must be “2b” .48 13/54 6 This is a dollar amount field. Amount from Line 2b (Spouse or CU Partner Social security,

railroad retirement, veteran’s benefits, taxable and nontaxable) .49 7/56 2 This is an alpha/numeric field. Department ID Code. Must be “2c” .50 13/56 6 This is a dollar amount field. Amount from Line 2c (Spouse or CU Partner Unemployment

compensation/worker’s compensation) .51 7/58 2 This is an alpha/numeric field. Department ID Code. Must be “2d” .52 13/58 6 This is a dollar amount field. Amount from Line 2d (Spouse or CU Partner Wages, salaries,

tips, etc .) . See instructions for dependent’s exempt income .53 7/60 2 This is an alpha/numeric field. Department ID Code. Must be “2e” .

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DRAFT 21 NOV 201254 13/60 6 This is a dollar amount field. Amount from Line 2e (Spouse or CU Partner Interest and

dividends) .55 29/24 2 This is an alpha/numeric field. Department ID Code. Must be “2f” .56 35/24 6 This is a dollar amount field. Amount from Line 2f (Spouse or CU Partner Interest on U. S.,

state, and municipal obligations, taxable and nontaxable) .57 29/26 2 This is an alpha/numeric field. Department ID Code. Must be “2g” .58 35/26 6 This is a dollar amount field. Amount from Line 2g (Spouse or CU Partner Alimony, support

money, child support, cash gifts) .58 29/28 2 This is an alpha/numeric field. Department ID Code. Must be “2h” .60 35/28 6 This is a dollar amount field. Amount from Line 2h (Spouse or CU Partner Business income).

If the amount is a loss, enter zero. See instructions for offsetting a loss.61 29/30 2 This is an alpha/numeric field. Department ID Code. Must be “2i” .62 35/30 6 This is a dollar amount field. Amount from Line 2i (Spouse or CU Partner Capital gains, taxable

and nontaxable) . If the amount is a loss, enter zero. See instructions for offsetting a loss.63 29/32 2 This is an alpha/numeric field. Department ID Code. Must be “2j” .64 35/32 6 This is a dollar amount field. Amount from Line 2j (Spouse or CU Partner Taxable pensions,

annuities, IRA and other retirement fund distributions) . (See instructions.)65 29/34 2 This is an alpha/numeric field. Department ID Code. Must be “2k” .66 35/34 6 This is a dollar amount field. Amount from Line 2k (Spouse or CU Partner Rental and royalty

income) . If the amount is a loss, enter zero. See instructions for offsetting a loss.67 29/36 2 This is an alpha/numeric field. Department ID Code. Must be “2l” .68 35/36 6 This is a dollar amount field. Amount from Line 2l (Spouse or CU Partner Farm/partnerships/S

Corporations/LLC/Estate or Trust Income) . If the amount is a loss, enter zero. See instructions for offsetting a loss.

69 29/38 2 This is an alpha/numeric field. Department ID Code. Must be “2m” .70 35/38 6 This is a dollar amount field. Amount from Line 2m (Spouse or CU Partner Other income).

Print source of Other income on Page 2 of this schedule .71 29/40 2 This is an alpha/numeric field. Department ID Code. Must be “2n” .72 35/40 6 This is a dollar amount field. Amount from Line 2n (Spouse or CU Partner TOTAL INCOME).

Add Lines 2a through 2m .

If there are figures other than “0” on any line of Column 3, remember to list the name(s) and social security number(s) of all OTHER PERSONS who had income and lived with you during 2012. DO NOT list Claimant or Spouse/CU Partner as “OTHER PERSONS” unless separated or divorced.

73 29/42 2 This is an alpha/numeric field. Department ID Code. Must be “3a” .74 35/42 6 This is a dollar amount field. Amount from Line 3a (Other Persons Cash public assistance and

relief) .75 29/44 2 This is an alpha/numeric field. Department ID Code. Must be “3b” .76 35/44 6 This is a dollar amount field. Amount from Line 3b (Other Persons Social security, railroad

retirement, veteran’s benefits, taxable and nontaxable) .77 29/46 2 This is an alpha/numeric field. Department ID Code. Must be “3c” .78 35/46 6 This is a dollar amount field. Amount from Line 3c (Other Persons Unemployment compensation/

worker’s compensation) .79 29/48 2 This is an alpha/numeric field. Department ID Code. Must be “3d” .80 35/48 6 This is a dollar amount field. Amount from Line 3d (Other Persons Wages, salaries, tips, etc.).

See instructions for dependent’s exempt income .81 29/50 2 This is an alpha/numeric field. Department ID Code. Must be “3e” .82 35/50 6 This is a dollar amount field. Amount from Line 3e (Other Persons Interest and dividends).83 29/52 2 This is an alpha/numeric field. Department ID Code. Must be “3f” .84 35/52 6 This is a dollar amount field. Amount from Line 3f (Other Persons Interest on U. S., state, and

municipal obligations, taxable and nontaxable) .85 29/54 2 This is an alpha/numeric field. Department ID Code. Must be “3g” .

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DRAFT 21 NOV 201286 35/54 6 This is a dollar amount field. Amount from Line 3g (Other Persons Alimony, support money,

child support, cash gifts) .87 29/56 2 This is an alpha/numeric field. Department ID Code. Must be “3h” .88 35/56 6 This is a dollar amount field. Amount from Line 3h (Other Persons Business income). If the

amount is a loss, enter zero. See instructions for offsetting a loss.89 29/58 2 This is an alpha/numeric field. Department ID Code. Must be “3i” .90 35/58 6 This is a dollar amount field. Amount from Line 3i (Other Persons Capital gains, taxable and

nontaxable) . If the amount is a loss, enter zero. See instructions for offsetting a loss.91 29/60 2 This is an alpha/numeric field. Department ID Code. Must be “3j” .92 35/60 6 This is a dollar amount field. Amount from Line 3j (Other Persons Taxable pensions, annuities,

IRA and other retirement fund distributions) . (See instructions.)93 49/24 2 This is an alpha/numeric field. Department ID Code. Must be “3k” .94 55/24 6 This is a dollar amount field. Amount from Line 3k (Other Persons Rental and royalty income).

If the amount is a loss, enter zero. See instructions for offsetting a loss.95 49/26 2 This is an alpha/numeric field. Department ID Code. Must be “3l” .96 55/26 6 This is a dollar amount field. Amount from Line 3l (Other Persons Farm/partnerships/S

Corporations/LLC/Estate or Trust income) . If the amount is a loss, enter zero. See instructions for offsetting a loss.

97 49/28 2 This is an alpha/numeric field. Department ID Code. Must be “3m” .98 55/28 6 This is a dollar amount field. Amount from Line 3m (Other Persons Other income). Print

source of Other income on Page 2 of this schedule .99 49/30 2 This is an alpha/numeric field. Department ID Code. Must be “3n” .100 55/30 6 This is a dollar amount field. Amount from Line 3n (Other Persons TOTAL INCOME). Add

Lines 3a through 3m .101 49/32 2 This is an alpha/numeric field. Department ID Code. Must be “1o” .102 55/32 6 This is a dollar amount field. Amount from Line 1o (Claimant Social Security and Medicare

tax withheld on wages . 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 .)

103 49/34 2 This is an alpha/numeric field. Department ID Code. Must be “1p” .104 55/34 6 This is a dollar amount field. Amount from Line 1p (Claimant Child support paid). 105 49/36 3 This is an alpha/numeric field. Department ID Code. Must be “1q1” .106 55/36 6 This is a dollar amount field. Amount from Line 1q1 (Claimant Business Expenses for Reservists).

Use the amount from Federal Form 1040, Line 24.107 49/38 3 This is an alpha/numeric field. Department ID Code. Must be “1q2” .108 55/38 6 This is a dollar amount field. Amount from Line 1q2 (Claimant Alimony paid). Use the amount

from Federal Form 1040, Line 31a.109 49/40 3 This is an alpha/numeric field. Department ID Code. Must be “1q3” .110 55/40 6 This is a dollar amount field. Amount from Line 1q3 (Claimant Tuition and Fees). Use the

amount from Federal Form 1040, Line 34 or 1040A, Line 19.111 49/42 3 This is an alpha/numeric field. Department ID Code. Must be “1q4” .112 55/42 6 This is a dollar amount field. Amount from Line 1q4 (Claimant Self-employed health insurance

deduction) . Use the amount from Federal Form 1040, Line 29.113 49/44 3 This is an alpha/numeric field. Department ID Code. Must be “1q5” .114 55/44 6 This is a dollar amount field. Amount from Line 1q5 (Claimant Health Savings account

deduction) . Use the amount from Federal Form 1040, Line 25.115 49/46 2 This is an alpha/numeric field. Department ID Code. Must be “1r” .116 55/46 6 This is a dollar amount field. Amount from Line 1r [Claimant sum of Lines 1o, 1p, 1q1, 1q2,

1q3, 1q4, and 1q5 (Fields #102, #104, #106, #108, #110, #112, and #114)] .117 49/48 2 This is an alpha/numeric field. Department ID Code. Must be “1s” .118 55/48 6 This is a dollar amount field. Amount from Line 1s (Claimant Subtract Line 1r from Line 1n).

If negative, enter “0”.119 49/50 2 This is an alpha/numeric field. Department ID Code. Must be “1u” .

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DRAFT 21 NOV 2012120 55/50 6 This is a dollar amount field. Amount from Line 1u (If Claimant was born 1/1/1948 and after,

Claimant interest and dividend income from Lines e and f .) If Claimant was born 1/1/1948 and after, combine amounts from Lines 1e and 1f (Fields #26 & #28). Otherwise enter “0”

121 49/52 2 This is an alpha/numeric field. Department ID Code. Must be “2o” .122 55/52 6 This is a dollar amount field. Amount from Line 2o (Spouse or CU Partner Social Security and

Medicare tax withheld on wages . 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 .)

123 49/54 2 This is an alpha/numeric field. Department ID Code. Must be “2p” .124 55/54 6 This is a dollar amount field. Amount from Line 2p (Spouse or CU Partner Child support paid). 125 49/56 3 This is an alpha/numeric field. Department ID Code. Must be “2q1” .126 55/56 6 This is a dollar amount field. Amount from Line 2q1 (Spouse or CU Partner Business Expenses

for Reservists) . Use the amount from Federal Form 1040, Line 24.127 49/58 3 This is an alpha/numeric field. Department ID Code. Must be “2q2” .128 55/58 6 This is a dollar amount field. Amount from Line 2q2 (Spouse or CU Partner Alimony paid).

Use the amount from Federal Form 1040, Line 31a.129 49/60 3 This is an alpha/numeric field. Department ID Code. Must be “2q3” .130 55/60 6 This is a dollar amount field. Amount from Line 2q3 (Spouse or CU Partner Tuition and Fees).

Use the amount from Federal Form 1040, Line 34 or 1040A, Line 19.131 69/22 3 This is an alpha/numeric field. Department ID Code. Must be “2q4” .132 75/22 6 This is a dollar amount field. Amount from Line 2q4 (Claimant Self-employed health insurance

deduction) . Use the amount from Federal Form 1040, Line 29.133 69/24 3 This is an alpha/numeric field. Department ID Code. Must be “2q5” .134 75/24 6 This is a dollar amount field. Amount from Line 2q5 (Spouse or CU Partner Health Savings

account deduction) . Use the amount from Federal Form 1040, Line 25.135 69/26 2 This is an alpha/numeric field. Department ID Code. Must be “2r” .136 75/26 6 This is a dollar amount field. Amount from Line 2r [Spouse or CU Partner sum of Lines 2o,

2p, 2q1, 2q2, 2q3, 2q4, and 2q5 (Fields #122, #124, #126, #128, #130, #132, and #134)] .137 69/28 2 This is an alpha/numeric field. Department ID Code. Must be “2s” .138 75/28 6 This is a dollar amount field. Amount from Line 2s [Spouse or CU Partner Subtract Line 2r

(Field #136) from Line 2n (Field #72)] . If negative, enter “0”.139 69/30 2 This is an alpha/numeric field. Department ID Code. Must be “2u” .140 75/30 6 This is a dollar amount field. Amount from Line 2u (Spouse or CU Partner interest and dividend

income .) If CLAIMANT was born 1/1/1948 and after, combine amounts from Lines 2e and 2f (Fields #54 & #56). Otherwise, enter “0”.

141 69/32 2 This is an alpha/numeric field. Department ID Code. Must be “3o” .142 75/32 6 This is a dollar amount field. Amount from Line 3o (Other Persons Social Security and Medicare

tax withheld on wages . 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 .)

143 69/34 2 This is an alpha/numeric field. Department ID Code. Must be “3p” .144 75/34 6 This is a dollar amount field. Amount from Line 3p (Other Persons Child support paid).145 69/36 3 This is an alpha/numeric field. Department ID Code. Must be “3q1” .146 75/36 6 This is a dollar amount field. Amount from Line 3q1 (Other Persons Business Expenses for

Reservists) . Use the amount from Federal Form 1040, Line 24.147 69/38 3 This is an alpha/numeric field. Department ID Code. Must be “3q2” .148 75/38 6 This is a dollar amount field. Amount from Line 3q2 (Other Persons Alimony paid). Use the

amount from Federal Form 1040, Line 31a.149 69/40 2 This is an alpha/numeric field. Department ID Code. Must be “3q3” .150 75/40 6 This is a dollar amount field. Amount from Line 3q3 (Other Persons Tuition and Fees). Use

the amount from Federal Form 1040, Line 34 or 1040A, Line 19.151 69/42 3 This is an alpha/numeric field. Department ID Code. Must be “3q4” .

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DRAFT 21 NOV 2012152 75/42 6 This is a dollar amount field. Amount from Line 3q4 (Other Persons Self-employed health

insurance deduction) . Use the amount from Federal Form 1040, Line 29.153 69/44 3 This is an alpha/numeric field. Department ID Code. Must be “3q5” .154 75/44 6 This is a dollar amount field. Amount from Line 3q5 (Other Persons Health Savings account

deduction) . Use the amount from Federal Form 1040, Line 25.155 69/46 2 This is an alpha/numeric field. Department ID Code. Must be “3r” .156 75/46 6 This is a dollar amount field. Amount from Line 3r [Other Persons sum of Lines 3o, 3p, 3q1,

3q2, 3q3, 3q4, and 3q5 (Fields #142, #144, #146, #148, #150, #152, and #154)] .157 69/48 2 This is an alpha/numeric field. Department ID Code. Must be “3s” .158 75/48 6 This is a dollar amount field. Amount from Line 3s [Other Persons Subtract Line 3r (Field

#156) from Line 3n (Field #100)] . If negative, enter “0”.159 69/50 2 This is an alpha/numeric field. Department ID Code. Must be “3t” .160 75/50 6 This is a dollar amount field. Amount from Line t. Add Lines 1s, 2s, and 3s (Fields #118,

#138 and #158). If negative, enter “0”.161 69/52 2 This is an alpha/numeric field. Department ID Code. Must be “3u” .162 75/52 6 This is a dollar amount field. Amount from Line 3u (Other Persons interest and dividend

income .) If CLAIMANT was born 1/1/1948 and after, combine amounts from Lines 3e and 3f (Fields #82 & 84). Otherwise, enter “0”.

163 69/54 2 This is an alpha/numeric field. Department ID Code. Must be “3v” .164 75/54 6 This is a dollar amount field. Amount from Line v. Add Lines 1u, 2u, and 3u (Fields #120,

#140, and #162).165 69/56 2 This is an alpha/numeric field. Department ID Code. Must be “3w” .166 76/56 5 This is a dollar amount field. Amount from Line w. Must be “10000” .167 69/58 2 This is an alpha/numeric field. Department ID Code. Must be “3x” .168 75/58 6 This is a dollar amount field. Amount from Line x. Subtract Line 3w (Field #166) from Line

3v (Field #164). If Line 3w is more than Line 3v, enter “0”.169 69/60 2 This is an alpha/numeric field. Department ID Code. Must be “3y” .170 75/60 6 This is a dollar amount field. Amount from Line y (HOUSEHOLD INCOME). Add Line 3t

(Field #160) and Line 3x (Field #168). HOMEOWNERS: If the amount on Line y is $99,000 or less, you should complete Form

HS-122, Section B. You may be eligible for a property tax adjustment. This schedule must be filed with the HS-122. Enter this amount on Form HS-122, Line B8 (HS-122, Field #55).

RENTERS: If the amount on Line y is $47,000 or less, enter this amount on Form PR-141, Line 6 (PR-141, Field #39).

If the amount is more than $999,999, DO NOT FILE THIS SCHEDULE AND DO NOT PRINT THE AMOUNT ON EITHER FORM HS-122 OR FORM PR-141. Claimant does not qualify for either of the above-listed programs.


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ID #

DRAFT 21 NOV 2012

Use this worksheet to determine if you may owe tax.

An extension only allows additional time to file the Vermont income tax return and avoids a late filing penalty. If tax is due, interest and late payment penalty accrue from the original due date of the return to the date of payment.

1. Estimated individual income tax liability. . . . . . . . . . . . . . . . . . . . 1. (year)2. Previous payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.

3. Amount of tax paid with this application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.

Vermont Department of TaxesPO Box 1779Montpelier, VT 05601-1779(866) 828-2865 or (802) 828-2865

VERMONT Form IN-151Application for Extension of Time to FileForm IN-111 VT Individual Income Tax Return

CompletethisapplicationifyouareunabletofileyourVermontIncomeTaxReturn before the due date of






Irequestanautomaticsix-monthextensionoftimetoOctober15,tofilemyVermontIncomeTaxReturn.

NOTE: An extension of time to file the VT individual income tax return does NOT apply to Homestead Declaration and Property Tax Adjustment Claim (Form HS-122), or Renter Rebate Claim (Form PR-141). These forms must be filed by their specific due dates.

Rev. 10/12 Form IN-151

TAX CALCULATION WORKSHEET

PAYMENT OPTIONS

Filing by paper: Make checks payable to Vermont Department of Taxes and mail with this form to the address above.

On-line payment: Go to VTPay on our website at http://tax.vermont.gov to pay by credit card and select the “Estimated Payment” option. (There is a convenience fee for payments over $200.)

1 2

3 4 5 6

7 8 9 10

11

12 13 14

*121513199** 1 2 1 5 1 3 1 9 9 *

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NOTE: This form is designed as a “generic year” form. Please leave the area for the year in the upper left corner blank on the template (blank form). (Yellow highlighted areas on Page 81 indicate the areas which should be blank on the template. The yellow highlighting is for reference purposes only and should not be included on your printed form.) The year should be printed at the same time as the variable data. The form must be submitted annually for approval.


1 7/27 2 This is an alpha field. Department ID Code. Must be “TY” .2 12/27 4 This is a numeric field. This is the Tax Year that this form is extending (2012). Must be 4

digits . Must be “2012” .3 7/29 20 This is an alpha field. Taxpayer’s Last Name. This is a REQUIRED ENTRY .4 31/29 20 This is an alpha field. Taxpayer’s First Name. This is a REQUIRED ENTRY .5 55/29 1 This is an alpha field. Taxpayer’s Middle Initial.6 60/29 9 This is a numeric field. Taxpayer’s Social Security Number. Must be 9 digits. This is a





if there is no Spouse or CU Partner, leave this field blank.11 7/33 35 This is an alpha/numeric field. Mailing Address.12 7/35 25 This is an alpha field. City or Town for mailing address.13 37/35 2 This is an alpha field . State for mailing address . Use the standard 2-character state

abbreviation .14 44/35 9 This is a numeric field. ZIP Code for mailing address. Must have 5 or 9 digits only. DO NOT



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DRAFT 21 NOV 20122012 IN-152 and IN-152A, Page 1 Specifications

Worksheets IN-152 and IN-152A do not have a scanband or a barcode . If including these worksheets in your software, please choose which version you will create -- Vendor version or Department version -- and use that version for both forms .

Vendor version:If you create the vendor version of these forms, you must also create and submit for approval the separate worksheets requested on these forms . The required worksheets to be submitted with IN-152 and IN-152A are:

• Calculation of Interest• Calculation of Penalty

These worksheets are to be of your own design and may be printed on one page or on multiple pages and must clearly state which worksheet it is .

Department version:If you create the Department version of these forms, separate worksheets are not required .

NOTE: Do not print “Vendor version” or “Department version” on your forms .

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ID #

DRAFT 21 NOV 2012


Schedule IN-153

2012 Capital Gain Exclusion Calculation Schedule IN-153 ATTACH TO FORM IN-111


*121533199** 1 2 1 5 3 3 1 9 9 *

5 6

43

21

8

9 10

7

11 12

13 14

15 16

17 18

19 20

21 22

23

25 26

27 28

29 30

31 32

33 34

35 36

37 38

39 40

41 42

43 44

45

47

46

48

49 50

51 52

53 54

55 56

57 58

24

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1 7/15 3 This is an alpha field. Department ID Code. Must be “SSN” .2 13/15 9 This is a numeric field. Taxpayer’s Social Security Number (same as Form IN-111, Field #25).3 7/17 1 This is a numeric field. Department ID Code. Must be “1” .4 13/17 9 This is a dollar amount field. Amount from Line 1 (Smaller of Line 15 or 16 from Federal

Form 1040, Schedule D) .5 7/19 2 This is an alpha/numeric field. Department ID Code. Must be “2a” .6 13/19 9 This is a dollar amount field. Amount from Line 2a (Federal Form 1040, Schedule D, Line 18) .7 7/21 2 This is an alpha/numeric field. Department ID Code. Must be “2b” .8 13/21 9 This is a dollar amount field. Amount from Line 2b (Federal Form 1040, Schedule D, Line 19) .9 7/23 1 This is a numeric field. Department ID Code. Must be “3” .10 13/23 9 This is a dollar amount field. Amount from Line 3 (Add Lines 2a and 2b).11 7/25 1 This is a numeric field. Department ID Code. Must be “4” .12 13/25 9 This is a dollar amount field. Amount from Line 4 (Subtract Line 3 from Line 1.)13 7/27 2 This is an alpha/numeric field. Department ID Code. Must be “5a” .14 13/27 9 This is a dollar amount field. Amount from Line 5a (Federal Form 4952, Line 4g) .15 7/29 2 This is an alpha/numeric field. Department ID Code. Must be “5b” .16 13/29 9 This is a dollar amount field. Amount from Line 5b (Federal Form 4952, Line 4e) .17 7/31 2 This is an alpha/numeric field. Department ID Code. Must be “5c” .18 13/31 9 This is a dollar amount field. Amount from Line 5c (Multiply Line 5a by Line 5b).19 7/33 2 This is an alpha/numeric field. Department ID Code. Must be “5d” .20 13/33 9 This is a dollar amount field. Amount from Line 5d (Federal Form 4952, Line 4b) .21 7/35 2 This is an alpha/numeric field. Department ID Code. Must be “5e” .22 13/35 9 This is a dollar amount field. Amount from Line 5e (Federal Form 4952, Line 4e) . Same as

Field #16 above.23 7/37 1 This is a numeric field. Department ID Code. Must be “6” .24 13/37 9 This is a dollar amount field. Amount from Line 6. Add Lines 5d (Field #20) and 5e (Field #22).25 7/39 1 This is a numeric field. Department ID Code. Must be “7” .26 13/39 9 This is a dollar amount field. Amount from Line 7. Divide Line 5c (Field #18) by Line 6

(Field #24).27 7/41 1 This is a numeric field. Department ID Code. Must be “8” .28 13/41 9 This is a dollar amount field. Amount from Line 8. Subtract Line 7 (Field #26) from Line 4

(Field #12). If less than zero, enter “0”.29 7/43 1 This is a numeric field. Department ID Code. Must be “9” .30 13/43 9 This is a dollar amount field. Amount from Line 9 [Enter the SMALLER of Line 8 (Field #28)

or $5,000] .31 46/15 2 This is a numeric field. Department ID Code. Must be “10” .

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DRAFT 21 NOV 201232 53/15 9 This is a dollar amount field. Amount from Line 10 (Amount from Part I, Line 4). Same as

Field #12 above.33 46/17 2 This is a numeric field. Department ID Code. Must be “11” .34 53/17 9 This is a dollar amount field. Amount from Line 11 (Adjusted net capital gain from the sale of

assets held for three years or less) . 35 46/19 2 This is a numeric field. Department ID Code. Must be “12” .36 53/19 9 This is a dollar amount field. Amount from Line 12 (Assets held for more than three years).

Subtract Line 11 (Field #34) from Line 10 (Field #32). If less than zero, enter “0”.37 46/21 3 This is an alpha/numeric field. Department ID Code. Must be “13a” .38 52/21 10 This is a dollar amount field. Amount from Line 13a (Real estate or portion of real estate used

as a primary or nonprimary home) . Put a hyphen (-) at the beginning of the amount to indicate a negative number .

39 46/23 3 This is an alpha/numeric field. Department ID Code. Must be “13b” .40 52/23 10 This is a dollar amount field. Amount from Line 13b. (Depreciable personal property except

for farm property or standing timber.) Put a hyphen (-) at the beginning of the amount to indicate a negative number .

41 46/25 3 This is an alpha/numeric field. Department ID Code. Must be “13c” .42 52/25 10 This is a dollar amount field. Amount from Line 13c (Stocks or bonds publicly traded or traded

on an exchange or any other financial instruments.). Put a hyphen (-) at the beginning of the amount to indicate a negative number .

43 46/27 2 This is a numeric field. Department ID Code. Must be “14” .44 52/27 10 This is a dollar amount field. Amount from Line 14. Add Lines 13a through 13c (Fields #38,

#40, and #42). Put a hyphen (-) at the beginning of the amount to indicate a negative number .45 46/29 2 This is a numeric field. Department ID Code. Must be “15” .46 53/29 9 This is a dollar amount field. Amount from Line 15 (Amount of net adjusted capital gain eligible

for exclusion) . Subtract Line 14 (Field #44) from Line 12 (Field #36).47 46/31 2 This is a numeric field. Department ID Code. Must be “16” .48 53/31 9 This is a dollar amount field. Amount from Line 16 [Amount from Part I, Line 7 (Field #26)

or recomputed Federal Form 4952] .49 46/33 2 This is a numeric field. Department ID Code. Must be “17” .50 53/33 9 This is a dollar amount field. Amount from Line 17. Subtract Line 16 (Field #48) from

Line 15 (Field #46).51 46/35 2 This is a numeric field. Department ID Code. Must be “18” .52 53/35 9 This is a dollar amount field. Amount from Line 19. Multiply Line 17 (Field #50) by 40%.53 46/37 2 This is a numeric field. Department ID Code. Must be “19” .54 53/37 9 This is a dollar amount field. Amount from Line 19 [Enter the greater of Line 9 (Field #30)

or Line 18 (Field #52)] .55 46/39 2 This is a numeric field. Department ID Code. Must be “20” .56 53/39 9 This is a dollar amount field. Amount from Line 20. Multiply IN-111, Line 11 (Form IN-111,

Field #39) by 40%.57 46/41 2 This is a numeric field. Department ID Code. Must be “21” .58 53/41 9 This is a dollar amount field. Amount from Line 21 (Capital gain exclusion). Enter the smaller

of Line 19 (Field #54) or Line 20 (Field #56) . Also enter this on Form IN-111, Line 14b (IN-111, Field #51).


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ID #

DRAFT 21 NOV 20122012 State/Local Income Tax Addback Schedule IN-154

Schedule IN-154


PART A 2012 Federal Form 1040, Schedule A Deduction 1. Enter amount of itemized deductions from Federal Form 1040, Schedule A, Line 29. . . . . . . . . . . . . . . . . . . . . . 1. 2. Enterallowablefederalstandarddeductionforyourfilingstatus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.

3. Subtract Line 2 from Line 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. 4. Enter amount of state and local income taxes from Federal Form 1040, Schedule A, Line 5 . . . . . . . . . . . . . . . . 4. 5. Allowable state and local income taxes deduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. 6. Subtract Line 5 from Line 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.

PART B Adjustment for Recapture of Excess 2011 Addback 7. Enter amount from your 2012 Federal Form 1040, Line 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. If entry is zero, skip Parts B & C and enter Line 6 on Form IN-111, Line 12c. 8. Enter amount from 2011 VT Schedule IN-154, Line 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 9. Enter the lesser of Line 7 or Line 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.

PART C Adjusted 2012 Addback 10. Subtract Line 9 from the lesser of Line 3 or Line 6. This is the 2012 addback amount. . . . . . . . . . . . . . . . . . . . 10. If the difference is less than zero, indicate a negative number.

Enter this amount on Form IN-111, Line 12c. If the difference is less than zero, indicate a negative number on Form IN-111, Line 12c.


You must complete this schedule if you filed Federal Form 1040, Schedule Aand your State and Local Income Taxes deduction for 2012 tax year on FederalForm 1040, Schedule A, Line 5 exceeds $5,000. ATTACH TO FORM IN-111

StandardSingle 5,950Married Filing Jointly or Qualifying Widow(er) 11,900Married Filing Separately 5,950Head of Household 8,700

For those born before January 1, 1948 or blind and entry on Federal Form 1040, Line 39a is

1 2 3 4 7,400 8,850 n/a n/a 13,050 14,200 15,350 16,500 7,100 8,250 9,400 10,550 10,150 11,600 n/a n/a

OR

123456789. 16200.

5 6

43

21

8

9 10

7

11 12

13 14

1615

1817

2019

2221

*121543199** 1 2 1 5 4 3 1 9 9 *

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#25).3 7/17 1 This is a numeric field. Department ID Code. Must be “1” .4 13/17 9 This is a dollar amount field. This is the figure on Line 1, Itemized deductions. Use the amount

from Federal Form 1040, Schedule A, Line 29.5 7/19 1 This is a numeric field. Department ID Code. Must be “2” .6 17/19 5 This is a dollar amount field. This is the figure on Line 2, Allowable federal standard deduction

for your filing status. Use the amount from applicable chart on form.7 7/21 1 This is a numeric field. Department ID Code. Must be “3” .8 13/21 9 This is a dollar amount field. This is the figure on Line 3. Subtract Line 2 (Field #6) from

Line 1 (Field #4). 9 7/23 1 This is a numeric field. Department ID Code. Must be “4” .10 13/23 9 This is a dollar amount field. This is the figure on Line 4, state and local income taxes. Use

the amount from Federal Form 1040, Schedule A, Line 5.11 7/25 1 This is a numeric field. Department ID Code. Must be “5” .12 18/25 4 This is a dollar amount field. This is the figure on Line 5, Allowable state and local income

taxes deduction . Must be “5000” .13 48/15 1 This is a numeric field. Department ID Code. Must be “6” .14 54/15 9 This is a dollar amount field. This is the figure on Line 6. Subtract Line 5 (Field #12) from

Line 4 (Field #10).15 48/17 1 This is a numeric field. Department ID Code. Must be “7” .16 54/17 9 This is a dollar amount field. This is the figure on Line 7. Use the amount from Federal

Form 1040, Line 10. If negative, enter “0”, enter default data (“0”) on Lines 8-10, and enter Line 6 (Field #14) amount on Form IN-111, Line 12c (Form IN-111, Field #45) .

17 48/19 1 This is a numeric field. Department ID Code. Must be “8” .18 54/19 9 This is a dollar amount field. This is the figure on Line 8. Enter amount from 2011 VT

Schedule IN-154, Line 6.19 48/21 1 This is a numeric field. Department ID Code. Must be “9” .20 54/21 9 This is a dollar amount field. This is the figure on Line 9. Enter the lesser of Line 7 (Field

#16) or Line 8 (Field #18) . 21 48/23 2 This is a numeric field. Department ID Code. Must be “10” .22 53/23 10 This is a dollar amount field. This is the figure on Line 10. Subtract Line 9 (Field #20) from

THE LESSER OF Line 3 (Field #8) or Line 6 (Field #14). Put a hyphen (-) at the beginning of the amount to indicate a loss . Enter this amount on Form IN-111, Line 12c (Form IN-111, Field #45).


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DRAFT 21 NOV 2012REW - SCHEDULE A Form RW-171FILE ORIGINAL ONLY. DO NOT COPY. ATTACH TO RW-171, PAGE 1.PLEASE TYPE OR PRINT CLEARLY. USE BLUE OR BLACK INK ONLY.

TO BE COMPLETED BY THE BUYER OR OTHER TRANSFEREE REQUIRED TO WITHHOLD

1. Check box to indicate whether SELLER is: Individual(s)* C-Corporation** Composite Business Entity** *Partnerships, S-Corporations, Trusts & LLC’s check “Individual(s)” and complete a Schedule A for each individual receiving proceeds from the sale. **C-Corporation and Composite Business Entity please see Line 1 instructions.

2. Taxpayer’s Social Security Number Spouse’s Social Security Number 3. Federal ID number of seller (if applicable)

4. Taxpayer’s Last Name First Name Initial

Spouse’s Last Name First Name Initial

C-Corporation Name or Composite Business Entity Name (if checked above)

5. Mailing Address (Number and Street or Road Name)

6. City or Town State Zip Code Check if this is an INTERNATIONAL address7. Location and description of property

8. Date property acquired by seller 9. Date of transfer 10. Total consideration

11. Percentage of total gross proceeds received by this seller 12. Amount withheld for this seller %

Pass-through information. If the individual above is a shareholder, partner or member of an S-corporation, Partnership or Limited Liability Com-pany and sold the real property, please identify the business. Do not complete Lines 13 & 14 if composite entity is checked on Line 1.

13. Name of Business 14. Federal ID Number


Form RW-171(Rev. 11/08)PAGE 2

DO NOT COPY. For additional Schedule “A”s, call (802) 828-2515.

5 8

13

16 17 18

14

19 20

4

7

12

15

321

11

6

21 22 23 24 25 26

9 10

*081713299** 0 8 1 7 1 3 2 9 9 *

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DRAFT 21 NOV 2012RW-171, rev. 11/08, Page 2 Specifications

• Use COURIER 12 POINT FONT for all printing in the scanband area .• DATA must be present IN ALL FIELDS unless otherwise specified. (See page 6)• DO NOT allow MORE characters in the taxpayer-readable portion than is allowed by “Field Length” . (See page 6)• DO NOT USE PUNCTUATION or symbols in the scanband . (See page 6)• Use ALL CAPITAL LETTERS for variable data alpha characters . (See page 6)è DOLLAR AMOUNTS MUST BE SHOWN WITH CENTS IN THE SCANBAND. This is different than our other

forms with scanbands . Examples: $1,598 .00 in the taxpayer-readable portion of the form would be shown as 159800 in the scanband; $2,356 .75 in the taxpayer-readable portion of the form would be shown as 235675 in the scanband . DO NOT ROUND DOLLAR AMOUNTS.

• Percentages are shown with an implied decimal point and two places to the right of the implied decimal point . (See page 7)

• Barcode begins at grid 58/4 and ends at grid 80/6.• Numbers beneath the barcode begin at grid 59/7 and end at grid 79/7. There is a space between each character. Use


NOTES: A. Page 1 of this form (see page 32) is not scanned . Reproduction of Form RW-171, Page 1 would follow the guidelines in our Substitute Forms Policy . Both pages must be submitted together to receive approval for Form RW-171 .

B. Line 1 check boxes, International address check box, and Lines 13 and 14 are intentionally not included in the scanband area .


1 7/45 20 This is an alpha field. Taxpayer’s Last Name (Line 4). If this is a C-Corporation, leave this field blank.

2 32/45 20 This is an alpha field. Taxpayer’s First Name (Line 4). If this is a C-Corporation, leave this field blank.

3 57/45 1 This is an alpha field. Taxpayer’s Middle Initial (Line 4). If this is a C-Corporation, leave this field blank.

4 63/45 9 This is a numeric field. This is Taxpayer’s Social Security Number (Line 2). MUST be 9 digits. If this is a C-Corporation, leave this field blank.

5 7/47 20 This is an alpha field. Spouse’s Last Name (Line 4). Must be included even if it is the same as Taxpayer’s Last Name . If there is no spouse, or if this is a C Corporation, leave this field blank.

6 32/47 20 This is an alpha field. Spouse’s First Name (Line 4). If there is no spouse, or if this is a C-Corporation, leave this field blank.

7 57/47 1 This is an alpha field. Spouse’s Middle Initial (Line 4). If there is no spouse, or if this is a C-Corporation, leave this field blank.

8 63/47 9 This is a numeric field. This is the Spouse’s Social Security Number (Line 2). MUST be 9 digits . If there is no spouse, or if this is a C Corporation, leave this field blank.

9 7/49 35 This is an alpha/numeric field . C-Corporation Name (Line 4) . If this is NOT for a C-Corporation, leave this field blank.

10 52/49 9 This is a numeric field. Federal ID number of seller, if applicable (Line 3). If seller does not have a Federal ID number, leave this field blank.

11 7/51 35 This is an alpha/numeric field. Mailing Address (Line 5).12 7/53 25 This is an alpha field. City or Town (Line 6).13 35/53 2 This is an alpha field. State (Line 6). Use the standard 2-character state abbreviation.14 42/53 9 This is a numeric field. ZIP Code (Line 6). Must be 5 or 9 digits only. DO NOT enter a

hyphen (-) or space between the 5-digit ZIP Code and the “+4” digits.15 7/55 2 This is an alpha/numeric field. Department ID Code. Must be “L7” .16 12/55 35 This is an alpha/numeric field. This is the location and description of property (Line 7).

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DRAFT 21 NOV 201217 62/55 2 This is an alpha/numeric field. Department ID Code. Must be “L8” .18 69/55 8 This is a numeric field. This is the date property was acquired by seller (Line 8). MMDDYYYY.

Must be 8 digits .19 7/57 2 This is an alpha/numeric field. Department ID Code. Must be “L9” .20 12/57 8 This is a numeric field. This is the date of transfer (Line 9). MMDDYYYY. Must be 8 digits.21 25/57 3 This is an alpha/numeric field. Department ID Code. Must be “L10” .22 31/57 10 This is a dollar amount field. This is the total consideration (Line 10). Use the amount from

Form RW-171, Page 1, Line 12. èDO NOT ROUND DOLLAR AMOUNT. SHOW CENTS IN THE SCANBAND.23 46/57 3 This is an alpha/numeric field. Department ID Code. Must be “L11” .24 52/57 5 This is a numeric amount . This is the percentage of total gross proceeds received by this seller

(Line 11) . That is, what percentage of RW-171, Page 1, Line 14 is this seller receiving? The percentage for all sellers of a particular sale should equal 100%.

25 62/57 3 This is an alpha/numeric field. Department ID Code. Must be “L12” .26 69/57 9 This is a dollar amount field. This is the amount withheld for this seller (Line 12). RW-171,

Page 1, Line 14 times RW-171, Page 2, Line 11. èDO NOT ROUND DOLLAR AMOUNT. SHOW CENTS IN THE SCANBAND.


Documents

STATE OF VERMONT DEPARTMENT OF TAXESwebservicesfp.lscsoft.com/downloads/forminstructions/2012/Vermo… · * Schedule HI-144 must be submitted with each subset (subsets 3 and 4)