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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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