APPLICATION FOR APPOINTMENT OF COUNSEL (Child Support Contempt) 400 - 00229 - Application for Appointment of Counsel (Child Support Contempt) (04/2018) Page 1 of 2 State of Vermont Vermont Superior Court Division Unit Docket Number FAMILY Name First Last Others Living with You (include adults and children) Street Address Town/City State Zip Telephone Number Date of Birth Social Security Number Total Number in Household (including Yourself) EMPLOYMENT Are you employed? Y es N o (s) and address (es) Employer(s) Name(s) and Address(es) : INCOME EXPENSES Yes No E nter your monthly household expenses Do you receive Public Assistance? ( including TANF/Reach UP; SSI, General Assistance) Do Any Family Members Living With You Receive Public Assistance Current Monthly Income Rent or Mortgage Pmt. $ You Other Household Members Living With You Electric Service $ Gross Income from Wages $ $ Phone $ Self Employment/Business Income (other than wages) $ $ Fuel (heat and/or gas) $ Unemployment Compensation $ $ Food $ Child Support $ $ Clothing $ Public Assistance $ $ Medical $ Other Income (Including Disability Insurance and Social Security) $ $ Child Support $ Total Income $ $ Auto Loan Payments $ Total Monthly Income ( Your income plus Household members) $ Property Taxes $ Total Income in the past 12 months $ Insurance ( Incl. Health, Auto, etc. ) $ I s your income in the last 30 days s ignificantly different from your monthly income during the previous year Y es N o Other Expenses $ If YES, please explain t he circumstances on the next page . Total Expenses $ C ash Assets Cash On Hand $ Checking Account $ Savings Account $ Total Cash Assets $ Additional Assets: I have additional assets: Y es N o If Yes, describe them below Vehicles Make, Model, Year Fair Market Value (FMV) Amount Owed Net value $ $ $ $ $ $ $ $ $ $ $ $ Real Property Description FMV Mortgage Net Value $ $ $ $ $ $ Other Assets e.g. tools, equipment, recreational vehicles, electronics, stocks, bonds, etc. Description FMV Use additional sheets as necessary. $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR APPOINTMENT OF COUNSEL (Child Support Contempt) 400 - 00229 - Application for Appointment of Counsel (Child Support Contempt) (04/2018) Page 2 of 2 Other Employed Household Members Name of Household Member Name of Employer Change in Monthly Income: If your current monthly income is significantly different from inc ome , please describe the reasons for the change . My income last year (past 12 months) was $ The income from other household members last year was: $ The reason for the change is : ( This section must be filled out if you have a change in income.) I request the Cou rt appoint an attorney for me in this case because of my low income. I further state that all of my answers are true to the best of my knowledge and belief , UNDER PENALTY OF PERJURY. Signed and sworn before me: Notary Public Date Applicant Signature Date DETERMINATION OF FINANCIAL ELIGIBILITY The Application is DENIED The gross income of the applicant and cohabiting family members is greater than 150% of the poverty line, AND welfare aid does not constitute a major portion of subsistence of the applicant and cohabit ing family members, AND the applicant is able to pay for an attorney without expending income or liquid resources necessary for the maintenance of the applicant and all dependents. The Application is GRANTED W elfare aid constitutes a major portion of subsistence of the applicant and cohabitating family members. OR T he gross income of the applicant and cohabiting family members is at or below 150% of the poverty income guidelines. OR A pplicant is unable to pay for an attorney without expending income or liquid resources necessary for the maintenance of the applicant and all dependents. Counsel is assigned . Signature of Clerk or Designee Date NOTICE OF RIGHT TO APPEAL: You have the right to appeal this order to the Judge of this C our t . Your appeal must be filed in writing with the clerk of this court within 7 days of the date of this order. American LegalNet, Inc. www.FormsWorkFlow.com