Vermont Department of Taxes     133 State Street     Montpelier, VT  05633-1401
Phone:  (802) 828-6851
     VT Form                VERMONT LAND GAINS                                                                   *191771100*
                      WITHHOLDING TAX RETURN                                                                     *191771100*
LGT-177               To be completed by Transferee (Buyer)                                                                                               Page 5

A.   TRANSFEROR’S (Seller’s) INFORMATION
     Entity TRANSFEROR Name                                                                                         Federal ID Number 

OR   Individual TRANSFEROR Last Name                      First Name                                     Initial OR Social Security Number

TRANSFEROR Mailing Address Following Transfer                                                                    Daytime Telephone Number

Line 2 for Mailing Address Following Transfer (if needed)                                                           For Department Use Only

City                                                                       State ZIP Code

Foreign Country (if not United States)                                     Email Address

                                                                                                                                                          FORM  (Place at FIRST page)
                                                                                                                                                          Form pages 

B.   TRANSFEREE’S (Buyer’s) INFORMATION
     Entity TRANSFEREE Name                                                                                         Federal ID Number 

OR   Individual TRANSFEREE Last Name                      First Name                                     Initial OR Social Security Number
                                                                                                                                                          5 - 6
TRANSFEREE Mailing Address Following Transfer                                                                    Daytime Telephone Number

Line 2 for Mailing Address Following Transfer (if needed)                                                           For Department Use Only

City                                                                       State ZIP Code

Foreign Country (if not United States)                                     Email Address

C.   PROPERTY INFORMATION
Property Physical Location - Number and Street or Road Name                                                      Land Size (in acres)

City or Town                                                               Check if property is located          SPAN  
                                                                           in multiple cities or towns

D.   HOLDING PERIOD
Date Acquired by Transferor (mm dd yyyy) Date of this Closing (mm dd yyyy)       Time Held
                                                                                                         _________ Years                 _________ Months 

                                                            (continued on next page)

                                                                                                                       Form LGT-177
                                                                                                                                     Page 1 of 2
5454                                                                                                                                 Rev. 12/19

Transferee’s Name _____________________________________________________
Property Location _____________________________________________________
Date of this Closing ____________________________________________________ 
                                                                                                                                     *191771200*
                                                                                                                                     *191771200*
                                                                                                                                                                                      Page 6

E. EXEMPTIONS
   E1.  If transfer is exempt from Land Gains Tax, enter exemption number   . . . . . . . . . .                                      E1.  ___________________________

           E1a.  If Line E1 is “08,” enter description  . . . . . . . . . . . . . . .  . E1a.  _________________________________________

   E2.  If a Vermont Commissioner’s Certificate issued, enter Certificate number   . . . . . .                                       E2.  ___________________________
   E3.  Is the transferor simultaneously filing a Form LGT-178 and paying the  
           full amount of tax due?  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .      E3.     Yes                                   No

F. TAX CALCULATIONS
If Lines E1, E2, or E3 do not apply, then:
   F1.  Sales price attributable to land .  
           (see instructions)  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . F1.  ___________________________
                                                                                                                                                                                      FORM  (Place at LAST page)
           OR                                                                                                                                                                         Form pages 
   F2.  Amount of Installment Sale payment subject to withholding  . . . . . . . . . . . . . . . . .                                 F2.  ___________________________

   F3.  Withholding tax rate  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .        F3.  ________________________10.00              %

   F4. TAX DUE        (Multiply Line F1 or Line F2 by Line F3)  . . . . . . . . . . . . . . . . . . . . . . F4. ___________________________                                           5 - 6
              •  If a Commissioner’s Certificate was issued, enter the withholding amount required.
              •  If simultaneously filing a Transferor (Seller) Form LGT-178, enter the amount shown due .  
              •  If an exemption is claimed on Line E1, enter -0- (or, if over allowable acreage, enter the amount shown due from 
               Form LGT-178).

G. SIGNATURES
We hereby certify this return is true, correct, and complete to the best of our knowledge.
   Signature of Primary Transferee                                        Printed name                                                                               Date

   May the Department of Taxes discuss this return with the preparer shown?                   c  Yes                                     c  No
           Preparer’s                                                                                                                    Date
           signature
           Preparer’s                                                                                                                    Preparer’s Telephone Number
           printed name
Preparer’s                                                                                                                               (                          )
           Firm’s name (or if self-employed, your name) and address
Use Only
           Preparer’s email address 

           Send completed return to:
                       Vermont Department of Taxes 
                       133 State Street 
                       Montpelier, VT  05633-1401
                                                                                                                                             Form LGT-177
                                                                                                                                                                     Page 2 of 2
5454                                                                                                                                                                     Rev. 12/19

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