Vermont Department of Taxes     133 State Street    Montpelier, VT  05633-1401 
Phone:  (802) 828-6851
   VT Form                                                                             *191741100*
                      LAND GAINS INSTALLMENT 
LGT-174
                      PAYMENT VOUCHER                                                  *191741100*                                             Page 1

BUYER
Last Name                                   First Name                         Initial                            Social Security Number 

Entity Name                                                                                                       Federal ID Number 

Address                                                                                                           For Department Use Only
City                                                   State ZIP Code

Foreign Country (if not United States) 

SELLER
Last Name                                   First Name                         Initial                            Social Security Number 
                                                                                                                                               FORM  (Place at FIRST page)
                                                                                                                                               Form pages
Entity Name                                                                                                       Federal ID Number 

Address                                                                                                           For Department Use Only
City                                                   State ZIP Code
                                                                                                                                               1 - 1
Foreign Country (if not United States) 

PROPERTY
Property Location (Physical street address)                                                                       Date Sold

City                                                   State ZIP Code                                             SPAN
                                                       VT

1.   Amount of this principal payment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1.  _________________________

2.   Total selling price (LG-2, Line 9) .......................................2.  _________________________

3.   Divide Line 1 by Line 2  ..............................................3.  _________________________

4.   Total tax due on sale (LG-2, Line 19) ....................................4.  _________________________

                                                                                                                                               FORM  (Place at LAST page)
5.   Amount due this payment (Multiply Line 3 by Line 4) ......................5.  _________________________
                                                                                                                                               Form pages

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                                                                                                                           Form LGT-174
5454                                                                                                                                Rev. 11/19

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