1. Federal Adjusted Gross Income (federal Form 1040, Line 11). . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 1. ___________________________ .00 2. Net Modifications to Federal AGI (Schedule IN-112, Part I, Line 17). . . . . . . . . . . . . . .. . . . . . . . . . . . . 2. ___________________________ .00 3. Federal AGI with Modifications (ADD Lines 1 and 2). . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 3. ___________________________ .00 4. 2021 Vermont Standard Deduction from filing status section above. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 4. ___________________________ .00

Please see instructions if you or your spouse checked any standard

deduction boxes on federal Form 1040, page 1. 5. Personal Exemptions:

5a. Enter “1” for yourself if no one can claim you as a dependent . . . . . . . . . . . . . . . . . . . . . . . . . . 5a. ________

5b. Enter “1” for your jointly filed spouse or CU partner if no one can claim them as a dependent or if you are a qualifying widow(er). . . . . . . . . . . . . . . . . . . . . . . . . 5b. ________

5c. Enter number of other dependents claimed on federal Form 1040. This includes any dependents other than yourself and/or your spouse. . . . . . . . . . . . . . . . . . . . . . 5c. ________

5d. ADD Lines 5a through 5c. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . 5d. _ ________ 5e. MULTIPLY Line 5d by $4,350 (2021 Personal Exemption). . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . 5e. ___________________________ .00 6. ADD Lines 4 and 5e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 6. ___________________________ .00 7. Vermont Taxable Income (SUBTRACT Line 6 from Line 3. If less than zero, enter -0-). . . . . . . . . . . 7. ___________________________ .00 8. Vermont Income Tax from tax table or tax rate schedule . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 8. ___________________________ .00 (If Line 1 is greater than $150,000, see instructions) 9. Net Adjustment to Vermont Tax (Schedule IN-119, Part I, Line 16). . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 9. ___________________________ .00 10. Vermont Income Tax with Adjustment (ADD Lines 8 and 9. If less than zero, enter -0-). . . . . . . . . . 10. ___________________________ .00

13. ___________________________ .00 14. Vermont Income Tax (Line 10 MINUS Line 13. If less than zero, enter -0-) . . . . . . . . . . . . . . . . . . . 14. ___________________________ .00 15. Income Adjustment (Schedule IN-113, Line 36, or 100. 0000%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 15. ________ . _________% 16. Adjusted Vermont Income Tax (MULTIPLY Line 14 by Line 15). . . . . . . . . . . . . . . . . . . . . . . . . . . . 16. _ _____________________________.00 Please PRINT in BLUE or BLACK INK DEPT USE ONLY FILE YOUR RETURN ELECTRONICALLY FOR A FASTER REFUND. GO TO TAX.VERMONT.GOV FOR MORE INFORMATION. 13. Charitable Contribution Deduction (Enter the lesser of Line 12 or $1,000) . . . . . . Form IN-111 Page 1 of 2 Rev. 10/21 Vermont Department of Taxes 2021 Form IN-111 Vermont Income Tax Return Amount Due (from Line 31) .00 ___________ .00 ___________ .00 11. Tax-Deductible Charitable Contribution 12. Multiply Line 11 by 5% (0. 05)

(See instructions)

Taxpayer’s Last Name First Name MI Social Security Number

Spouse’s/CU Partner’s Last Name First Name MI Social Security Number

Mailing Address (Number and Street/Road or PO Box) 911/Physical Street Address on 12/31/2021

City State ZIP Code or Foreign Postal Code Foreign Country Vermont School District Code

Check if Deceased Check if Deceased AMENDED Return RECOMPUTED Return Qualifying Widow(er) ($12,700) Head of Household ($9,500) Married/CU Filing Separately ($6,350) Married/CU Filing Jointly ($12,700) Single ($6,350) Filing Status and Standard Deduction Enter Healthcare Coverage Code (See instructions for code options)

EXTENDED Return Check all that apply *211111100* * 2 1 1 1 1 1 1 0 0 * 5454

Keep a copy for your records. Form IN-111 Page 2 of 2 Rev. 10/21 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. Other State Credit (Schedule IN-117, Line 21) Vermont Tax Credits (Schedule IN-119, Part II) Total Vermont Credits (Add Lines 17 and 18) OR Check to certify no Use Tax is due. Check if the Department of Taxes may discuss this return with the preparer shown. For Amended Returns Only:

Original refund received Refund due now Original payment Amount due now .00 .00 .00 .00 Signature Date (MM/DD/YYYY) Date of Birth (MM/DD/YYYY) Daytime Telephone Number Signature (If a joint return, BOTH must sign. ) Date (MM/DD/YYYY) Date of Birth (MM/DD/YYYY) Daytime Telephone Number Paid Preparer’s Signature

Date Preparer’s Telephone Number Firm’s Name (or yours if self-employed) and address

Preparer’s SSN or PTIN FEIN / / / / Green Up Vermont Total Contributions Vermont Veterans Fund Children’s Trust Fund Nongame Wildlife Fund / / *211111200* * 2 1 1 1 1 1 2 0 0 * Amount from Line 16 .00

Taxpayer’s Last Name Social Security Number 17. _____________________.00 + 18._____________________ .00 = 19. ___________________________ .00 20. Vermont Income Tax after credits (SUBTRACT Line 19 from Line 16. If Line 19 is greater than Line 16, enter -0-). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20. ___________________________ .00 21. Use Tax for taxable items on which no sales tax was charged, including online purchases. (See instructions, worksheet, and chart). . . . 21. ___________________________ .00 22. Total Vermont Taxes (ADD Lines 20 and 21) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22. ___________________________ .00 23a. _________.00 + 23b. _________.00 + 23c. _________.00 + 23d. _________.00 = 23e.____________ .00 24. Total of Vermont Taxes and Voluntary Contributions (ADD Lines 22 and 23e). . . . . . . . . . . . . . . . . . 24. ___________________________ .00 25a. 2021 Vermont Tax Withheld from W-2, 1099. . . . . . . . . . . . . . . . . . . . 25a. ___________________ .00 25b. 2021 Estimated Tax payments, amount carried forward from 2020, and/or payment made with 2021 extension. . . . . . . . . . . . . . . . . . . . . . . 25b. ___________________ .00 25c. Refundable Credits (Schedule IN-112, Part II, Line 11) . . . . . . . . . . . . 25c. ___________________ .00 25d. 2021 Vermont Real Estate Withholding from Form RW-171. . . . . . . . 25d. ___________________ .00 25e. 2021 Nonresident Estimated Tax payments (nonresident withholding) allocated on Schedule K-1VT, Line 5. . . . . 25e. ___________________ .00 25f. Total Payments and Credits (ADD Lines 25a through 25e). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25f. ___________________________ .00 26. Overpayment. If Line 24 is less than Line 25f, SUBTRACT Line 24 from Line 25f. . . . . . . . . . . . 26. ___________________________ .00 27a. Refund to be credited to 2022 Estimated Tax Payment. . . . . . . . . . . . . 27a. ___________________ .00 27b. Refund to be credited to 2022 Property Tax Bill. . . . . . . . . . . . . . . . . . 27b. ___________________ .00 28. REFUND AMOUNT (SUBTRACT Lines 27a and 27b from Line 26). . . . . . . . . . . . . . . . . . . . . . . 28. ___________________________ .00 29. If Line 24 is more than Line 25f, subtract Line 25f from Line 24. See instructions on tax due. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29. ___________________________ .00 30. Interest and Penalty on

31. AMOUNT DUE

Underpayment of Estimated Tax. . . 30. _________________.00 (ADD Lines 29 and 30).31. ___________________________ .00 (Worksheet IN-152 or IN-152A) 5454 Clear ALL fields Save and go to Important Printing Instructions Save and Print