Form Pr-141 - Vermont Renter Rebate Claim For Household Income Of 47,000 Or Less - 2012
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2Please PRINT in
*121411199*
DUE DATE: April 15, 2013 (Claims allowed up to Oct. 15, 2013)
BLUE or BLACK INK
Renter Rebate Claim
2012
FORM
* 1 2 1 4 1 1 1 9 9 *
PR-141
VERMONT
FOR HOUSEHOLD INCOME OF $47,000 OR LESS
For the year Jan. 1–Dec. 31, 2012
Must Be Filed With: Household Income (Schedule HI -144) and Landlord’s Certificate (LC-142)
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Claimant’s Social
Spouse or CU Partner
Claimant’s
Security Number
Social Security Number
Date of Birth
Claimant’s
First
Initial
Last Name
Name
Spouse or
First
CU Partner
Initial
Name
Last Name
Mailing Address
(Number and Street/
Road or PO Box)
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Zip
City/Town
State
Code
Location of rental property
1.
VT School
2. City/Town of Legal Residence on 12/31/2012
State
District Code
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 on page 44 for exception.
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Q1. Were you domiciled in VT all of calendar year 2012? . . . . . . . . . . . . . . . . . . .
Yes, Go to Q2 .
No, STOP. You are not eligible .
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Q2. Were you claimed as a dependent by another taxpayer in 2012? . . . . . . . . . . .
Yes, STOP. You are not eligible .
No, Go to Q3 .
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Q3. Did you rent in VT all 12 months in calendar year 2012? . . . . . . . . . . . . . . . .
Yes, Complete this form
No, STOP. You are not eligible .
Before doing rebate calculation, complete Household Income (Schedule HI-144).
REBATE CALCULATION
YOU MUST ATTACH SCHEDULE HI-144 AND THE LC-142 TO THIS FORM.
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0 0
3. ALLOCABLE RENT (LC-142, Line 16) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.
0 0 %
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4. HOME USE. If more than 25% of this rental is used for business, see instructions .
If no business use, enter 100 .00% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.
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0 0
5. ALLOWABLE RENT FOR REBATE CLAIM (Multiply Line 3 by Line 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.
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0 0
6. HOUSEHOLD INCOME (Schedule HI-144, Line y) If more than $47,000, you are not eligible . 6.
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6a. If AMENDED SCHEDULE HI-144, Household Income, is attached, check here .
%
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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:
2.0%
4.5%
5.0%
.
0 0
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
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0 0
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.
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge
and belief, they are true, correct and complete . Preparers cannot use return information for purposes other than preparing returns .
Signature
Date
Telephone Number
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Signature. If a joint return, BOTH must sign.
Date
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Check here if authorizing the VT Department of Taxes to discuss this return and attachments with your preparer.
Preparer’s signature
Date
Preparer’s
SSN or
Preparer’s
PTIN
Use Only
Firm’s name (or yours if self-employed) and address
EIN
Preparer’s Telephone Number
Keep a copy for your records.
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Form PR-141
MAIL TO: VT Department of Taxes, PO Box 1881, Montpelier, VT 05601-1881
5454
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