Renters Rebate Sample Form
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 no business use, enter 100.00% ...................................................4. _______________________
5. ALLOWABLE RENT FOR REBATE CLAIM (Multiply Line 3 by Line 4) ............................................5. ________________________
6. HOUSEHOLD INCOME (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. c
7. MAXIMUM PERCENTAGE OF INCOME FOR RENT ..............................7. _______________________
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 (Subtract Line 8 from Line 5 and enter result here.) If result is zero, you do not qualify
for a rebate. If filing this form with the VT Income Tax Return, also enter this amount on Form IN-111, Line 31d. ......... è 9. ________________________
MAXIMUM REBATE AMOUNT IS $3,000.
ALL eligibility questions must be answered. You must have rented all 12 months in 2013. See instructions on page 44 for exception.
Q1. Were you domiciled in VT all of calendar year 2013? ................... c Yes, Go to Q2. c No, STOP. You are not eligible.
Q2. Were you claimed as a dependent by another taxpayer in 2013? ........... c Yes, STOP. You are not eligible. c No, Go to Q3.
Q3. Did you rent in VT all 12 months in calendar year 2013? ................ c Yes, Complete this form c No, STOP. You are not eligible.
Before doing rebate calculation, complete Household Income (Schedule HI-144).
YOU MUST ATTACH SCHEDULE HI-144 AND THE LC-142 TO THIS FORM.
REBATE CALCULATION
Form PR-141
Must Be Filed With: Household Income (Schedule HI -144) and Landlord’s Certificate (LC-142)
*131411100*
*131411100*
FORM
PR-141
Renter Rebate Claim
2013
VERMONT
FOR HOUSEHOLD INCOME OF $47,000 OR LESS
For the year Jan. 1–Dec. 31, 2013
25
DUE DATE: April 15, 2014 (Claims allowed up to Oct. 15, 2014)
Please PRINT in
BLUE or BLACK INK
Keep a copy for your records.
MAIL TO: VT Department of Taxes, PO Box 1881, Montpelier, VT 05601-1881
If Line 6 Household Income is: $0 – 9,999 $10,000 – 24,999 $25,000 – 47,000
Enter this % on Line 7: 2.0% 4.5% 5.0%
Signature Date Telephone Number
Signature. If a joint return, BOTH must sign. Date
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.
Preparer’s
Use Only
Preparer’s signature Date Preparer’s
SSN or
PTIN
Firm’s name (or yours if self-employed) and address EIN
Preparer’s Telephone Number
Check here if authorizing the VT Department of Taxes to discuss this return and attachments with your preparer.
5454
Page 25
Attach Schedule HI-144 and Form LC-142
Claimant’s Last Name First Name Initial Claimant’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/Road or PO Box) Claimant’s Date of Birth (MM DD YYYY)
City State ZIP Code
Location of rental property (number, street/road name (Do not use “PO Box”, “same”, or Town name)
1. VT School District Code 2. City/Town of Legal Residence on 12/31/2013 State
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