Form 8879 Vt – Fill Out and Use This PDF

Part I	Last Name	First Name and Initial			Enter Social Security Number (SSN)
					-	-
Remember	Spouse’s Last Name (if different and joint return)	First Name and Initial			Enter Spouse’s SSN, if joint return
					-	-
to write in
your Social	Current Mailing Address			e-mail address
Security
Number	City or Town		State	Zip Code	Telephone Number
					(	)

Part II Tax Return Information (whole dollars only)

1.	Federal Taxable Income (Form IN-111, Section 3, Line 11)		1.	_____________________
2.	Vermont Taxable Income (Form IN-111, Section 3, Line 15)		2.	_____________________
3.	Adjusted VT Income Tax (Form IN-111, Section 4, Line 22)		3.	_____________________
4.	Vermont income tax withheld (Form IN-111, Section 7, Line 31a)		4.	_____________________
5.	Vermont Earned Income Tax Credit (Form IN-111, Section 7, Line 31c)		5.	_____________________
6.	Overpayment credited to 2010 estimated tax (Form IN-111, Section 8, Line 33a)		6.	_____________________
7.	Overpayment credited to 2010 property tax bill (Form IN-111, Section 8, Line 33b)		7.	_____________________
8.	Refund (Form IN-111, Section 8, Line 34)	(check applicable box)
	Amount Due (Form IN-111, Section 9, Line 37)
		. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	8.	_____________________

O DO NOT MAIL THIS FORM -- KEEP THIS FORM AND REQUIRED ATTACHMENTS ON FILE FOR 3 YEARS O

Part III Form HS-122 For Vermont Residents Only (check one box)

Declaration of VT Homestead form only		Declaration of VT Homestead & Property Tax Adjustment application
Part IV	Direct Deposit of Refund	ACH Debit Payment Amount $____________ Payment Date ____/____/2010

Part V Declaration of Taxpayer

By signing below, you agree that:

•Under penalties of perjury, I declare the information I provided to my Electronic Return Originator (ERO) and the amounts shown in Part II agree with the amounts shown on the corresponding lines of my 2009 Vermont Individual Income tax return and is, to the best of my knowledge and belief, true, accurate and complete.

•If making an ACH Debit Payment, I authorize the Department to withdraw funds from my account in the amount and on the date specified.

•I consent to have the ERO forward my return, including this declaration and accompanying schedules and statements, to the Vermont Department of Taxes upon the Department’s request.

•If the Vermont Department of Taxes does not receive full and timely payment of the amount due, I am liable for the tax and any applicable charges.

•I authorize the Department to disclose to the ERO the reason my refund is delayed and to confirm to the ERO the date my refund is sent.

Please Your SignatureSpouse’s Signature (if joint return, BOTH must sign)DateDateSign Here

Part VI Declaration of Electronic Return Originator (ERO) Only

As an ERO, I am not responsible for review of the taxpayer’s return but declare this form accurately reflects the data on the return. The taxpayer(s) signed this form before I submitted the return. I will give the taxpayer a copy of all forms and information to be filed with Vermont.

	ERO’s		Date	Check if: paid preparer
Electronic	signature			self-employed
Return
Originator’s	Firm’s name (or		EIN
Use Only	yours if self-
	employed) and		Phone Number
	address
		e-mail address:

Part VII Declaration of Paid Preparer

Under penalties of perjury, I declare that I have examined the above taxpayer’s return and accompanying schedules and statement. To the best of my knowledge and belief, they are true, correct and complete. This declaration is based on all information of which I have knowledge.

	Preparer’s				Date	Check if
Paid	signature					self-employed
Preparer’s	Firm’s name (or
Use Only					EIN
	yours if self-
	employed) and				Phone Number
	address
				e-mail address: