Form 804 AFFIDAVIT STATE OF VERMONT SUPERIOR COURT Unit Plaintiff's Name DOB FAMILY DIVISION Docket No. v. Defendant's Name DOB In support of the complaint, motion, petition or objection filed in this case, subject to the penalties for perjury, I state the following facts, which are true to the best of my knowledge and belief: Signature Date Subscribed and sworn to before me: Signature of Notary 1/11 SML Date Expiration Date American LegalNet, Inc. www.FormsWorkFlow.com