Page 25
If Line 8 Household Income is: $0 – 9,999 $10,000 – 24,999 $25,000 – 47,000
Enter this % on Line 9: 2.0% 4.5% 5.0%
MAXIMUM REBATE AMOUNT IS $3,000.
Form PR-141
Rev. 10/20
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.
Page 1 of 1
Vermont Department of Taxes
2020 Form PR-141
Vermont Renter Rebate Claim
For the year Jan 1 - Dec 31, 2020
Yes, Go to Line 2.
No, STOP. You are not eligible.
Yes, STOP. You are not eligible. No, Go to Line 3.
Yes, Complete this form. No, STOP. You are not eligible.
Check if the Department of Taxes may discuss this return with the preparer shown.
Check here if amended Schedule
HI-144, Household Income, is included.
IMPORTANT: This form MUST be filed with Schedule HI-144 and Form LC-142
or your claim will be considered incomplete.
Signature Date (MMDDYYYY) Daytime Telephone Number
Signature (If a joint return, BOTH must sign.) Date (MMDDYYYY) Daytime Telephone Number
Paid Preparer’s Signature Date (MMDDYYYY) Preparer’s Telephone Number
Firm’s Name (or yours if self-employed) and address Preparer’s SSN or PTIN FEIN
Claimant’s Last Name First Name MI Claimant’s Social Security Number
Spouse’s/CU Partner’s Last Name First Name MI Spouse’s or CU Partner’s Social Security Number
Mailing Address (Number and Street/Road or PO Box) Claimant’s Date of Birth (MM/DD/YYYY)
City State ZIP Code
Vermont School District Code 911/Physical Street Address on 12/31/2020 City/Town of Legal Residence on 12/31/2020 & State
Will you be using Renter Rebate
to pay Income Tax liability?
Head of
Household
Married/CU
Filing Separately
Married/CU
Filing Jointly
Single
Federal
Filing Status
Yes
No
/ /
-
REBATE CALCULATION: Before doing rebate calculation, complete Household Income (Schedule HI-144).
You MUST Include Schedule HI-144 and Form LC-142 with this form.
*201411100*
*201411100*
ELIGIBILITY QUESTIONS: ALL questions must be answered. You must have rented all 12 months in 2020. See instructions for exception.
1. Were you domiciled in Vermont all of calendar year 2020? ........
2. Were you claimed as a dependent by another taxpayer in 2020? ....
3. Did you rent in Vermont all 12 months in calendar year 2020? ......
4. E-file Certificate Number (from Form LC-142) ..........................4. _______________________________________________________
5. Allocable Rent (from Form LC-142, Line 9) ............................5. ______________ .00
6. Home Use. If more than 25% of this rental is used for business,
see instructions. If no business use, enter 100.00% .......................6. ________._______%
7. Allowable Rent for Rebate Claim (Multiply Line 5 by Line 6) ............................................7. _______________ .00
8. Household Income (from Schedule HI-144, Line z).
If more than $47,000 you are not eligible. ..............................8. ______________ .00
9. Maximum Percentage of Income for Rent .................................. 9. _____._____%
10. Maximum Rent for Household Income (Multiply Line 8 by Line 9 and enter result here.
If Line 10 is more than Line 7, you do not qualify for a renter rebate
......................................10. _______________ .00
11.
Renter Rebate Amount (Subtract Line 10 from Line 7 and enter result here.) If result is zero,
you do not qualify for a rebate.
....................................................................11. _________________.00
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Clear ALL fields
Save and go to Important Printing Instructions
Save and Print
Page 29
Please PRINT in BLUE or BLACK INK
This schedule must be included with the 2020 Renter Rebate Claim (Form PR-141) OR the 2021 Property Tax Credit Claim (Form HS-122).
Please read instructions before completing schedule.
List the names and Social Security Numbers of all other persons (in addition to a Spouse or CU Partner) who had income and lived with you during
2020. Include both their taxable and non-taxable income in Column 3. If you have more than two “Other Persons” living in your household, record the
names and Social Security Numbers on a separate sheet of paper and include with the filing.
Yearly totals of ALL
members of the household
1. Claimant /Claimant
and jointly filed Spouse
2. Filing separately
Spouse or CU Partner
3. Other Persons
Schedule HI-144
Rev. 10/20
a. Cash public assistance and relief (See instructions for exclusions) ... a. ____________.00 ____________.00 ___________ .00
b. Social Security, SSI, disability, railroad retirement,
veteran’s benefits, taxable and nontaxable . . . . . . . . . . . . . . . . . . . . . . b. ____________.00 ____________.00 ___________ .00
c. Unemployment compensation/worker’s compensation ............. c. ____________.00 ____________.00 ___________ .00
d. Wages, salaries, tips, etc. (See instructions for
dependent’s exempt income.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. ____________.00 ____________.00 ___________ .00
e. Interest and dividends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e. ____________.00 ____________.00 ___________ .00
f. Interest on U.S., state, and municipal obligations,
taxable and nontaxable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .f. ____________.00 ____________.00 ___________ .00
g. Alimony and support money . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . g. ____________.00 ____________.00 ___________ .00
h. Child support and cash gifts
Please specify__________________________ ..................h. ____________.00 ____________.00 ___________ .00
i. Business income. If the amount is a loss, enter -0-.
See instructions for offsetting a loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . i. ____________.00 ____________.00 ___________ .00
j. Capital gains, taxable and nontaxable. If the amount is a loss,
enter -0-. See instructions for offsetting a loss ...................j. ____________.00 ____________.00 ___________ .00
k. Taxable pensions, annuities, IRA and other retirement fund and
distributions. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . k. ____________.00 ____________.00 ___________ .00
l. Rental and royalty income. If the amount is a loss, enter -0-.
See instructions for offsetting a loss . . . . . . . . . . . . . . . . . . . . . . . . . . . .l. ____________.00 ____________.00 ___________ .00
m. Farm/partnerships/S corporations/LLC/Estate or Trust income.
If the amount is a loss, enter -0-. See Line m instructions for only
exception to offset a loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .m. ____________.00 ____________.00 ___________ .00
n. Other income (see instructions for examples of other income)
Please specify__________________________ ..................n. ____________.00 ____________.00 ___________ .00
o. Total Income: Add Lines a through n . . . . . . . . . . . . . . . . . . . . . . . . o. _____________.00 _____________ .00 _____________.00
Page 1 of 2
Claimant’s Last Name First Name MI Claimant’s Social Security Number
Spouse’s/CU Partner’s Last Name First Name MI Claimant’s Date of Birth (MMDDYYYY)
Vermont Department of Taxes
2020 Schedule HI-144
Household Income
For the year Jan 1 - Dec 31, 2020
Other Person #1 Last Name First Name MI Other Person #1 Social Security Number
Other Person #2 Last Name First Name MI Other Person #2 Social Security Number
FORM (Place at FIRST page)
Form pages
29 - 30
*201442100*
*201442100*
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p. See instructions. Enter Social Security and
Medicare tax withheld on wages claimed on
Line d. 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.
Include W-2 and/or Federal Schedule SE
if not included with income tax filing ..... p.____________ .00 ____________ .00 ____________.00
q. Child support paid. You must include
proof of payment. See instructions ....... q._____________ .00 _____________ .00 _____________ .00
r. Allowable adjustments from Federal Form 1040
r1. Business expenses for Reservists ....r1. ___________ .00 ____________ .00 ____________.00
r2. Alimony paid ...................r2. ___________ .00 ____________ .00 ____________.00
r3. Self-employed health
insurance deduction ...............r3. ___________ .00 ____________ .00 ____________.00
r4. Health Savings Account deduction ...r4. ___________ .00 ____________ .00 ____________.00
r5. Tuition and Fees as reported on
federal Form 8917 ................r5. ___________ .00 ____________ .00 ____________.00
s. Add Lines p, q, and total of Lines r1 to r5
for each column .......................s. ___________ .00 ____________ .00 ____________.00
t. Subtract Line s from Line o of each column.
If a negative amount, enter -0- . ...........t. ___________ .00 ____________ .00 ____________.00
u. Add all three amounts from Line t. If a negative amount, enter -0- .............................................u. ___________ .00
v. Complete if born Jan. 1, 1956 and after.
Enter interest and dividend income from
Lines e and f. .........................v. ___________ .00 ____________ .00 ____________.00
w. Add all three amounts from Line v ..................................................................... w. ___________ .00
x. Asset Adjustment of Interest and Dividend Income (Lines e and f). Per 32 V.S.A. § 6061E .........................x. _______________
y. Subtract Line x from Line w. If Line x is more than Line w, enter -0- . .........................................y. ___________ .00
z. HOUSEHOLD INCOME. Add Line u and Line y .........................................................z. ___________ .00
RENTERS If Line z Household Income is $47,000 or less, you may be eligible for a renter rebate. Complete Form PR-141 Renter Rebate Claim.
This schedule must be filed with the Renter Rebate Claim. Claims are due April 15, 2021, but can be filed up to Oct. 15, 2021.
If Household Income is more than $47,000, you do not qualify for a renter rebate.
HOMEOWNERS Form HS-122, Homestead Declaration AND Property Tax Credit Claim, must be filed each year.
Homeowners with Household Income up to $138,500 on Line z should complete Form HS-122, Section B. You may be eligible for
a property tax credit. This schedule must be filed with Form HS-122.
Form HS-122 The due date to file is April 15, 2021. Homeowners filing a property tax credit, Form HS-122 and Schedule HI-144,
between April 16 and Oct. 15, 2021, may still qualify for a Property Tax Credit. A $15 late filing fee will be deducted from
the credit.
Schedule HI-144
Rev. 10/20Page 2 of 2
Claimant’s Last Name Social Security Number
Support paid to: Last Name First Name MI Social Security Number
10,000.00
1. Claimant /Claimant
and jointly filed Spouse
2. Filing separately
Spouse or CU Partner
3. Other Persons
Carried forward from Line o ......_____________ .00 _____________ .00 _____________ .00
FORM (Place at LAST page)
Form pages
29 - 30
*201442200*
*201442200*
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