Fill and Sign the Form Hs 122 Vermont Department of Taxes Vermontgov

DECLARATION AND CLAIM OF HOMESTEAD Effective date: County and State where Real Property is located: ______________________________________________________________________________________ Claimant:(Name, Mailing Address and Zip Code): Spouse of Claimant: (Name, Mailing Address and Zip Code): __________________________________________________________________________________________ Homestead: Address or Location __________________________________________________________________________________________ Homestead: Legal Description 1. I am over the age of 18 and at the time of making this declaration actual ly am a resident of the State of _________. 2. I select and designate this Real Property or Mobile Home to be my Homestead, t ogether with the improvements thereon and the appurtenances thereto, as exempt from attachment, executi on or forced sale up to the amount of $150,000.00. I have designated this as my one and only Homestead and it s fair market value (minus liens and encumbrances) is $ ____________________. 3. My Real Property Homestead is in one compact body; upon which exists a dwelling house in which I reside, should I have designated a Mobile Home, my Homestead is a Mobile Home in whi ch I reside or a Mobile Home in which I reside and the land upon which it is located. 4. If I am married and the property being claimed is held as community or joint propert y, then my spouse joins with me in making this claim. [ ] The value of my Real Property Homestead (dwelling house and/or land), over and above encumbrance s against it, does not exceed $150,000.00. [ ] The value of my Mobile Home, over and above encumbrances, does not exceed $150,000.00. [ ] The value of my Mobile Home plus the value of the land upon which it is located, ove r and above encumbrances against them do not exceed $150,000.00 [ ] The value of my equity interest in one apartment of a horizontal property space does not exceed $100,000.00. [ ] The value in my Real Property Homestead, Mobil Home plus land, or apartment over and a bove encumbrances against them exceeds $150,000.00 in which case I claim the maximum exe mption allowable by law. ______________________________________ ____________________________________ Signature of Claimant Signature of Claimant's Spouse ______________________________________ ____________________________________ Signature of Claimant Signature of Claimant's Spouse STATE OF _________ ) )ss Acknowledged before me this _____ day of ______________, 20_____ County of _______________ ) by ________________________________________________________ Notary Public ___________________________________________ ( seal ) STATE OF _________ ) )ss Acknowledged before me this _____ day of ______________, 20_____ County of _______________ ) by ________________________________________________________ Notary Public ___________________________________________ ( seal )