VERMONT FAMILY COURT MEDIATION PROGRAM Notice: You are required to provide proof of income. APPLICATION FOR SUBSIDY THIS INFORMATION IS USED TO DETERMINE QUALIFICATION FOR SUBSIDY ONLY AND IS NOT KEPT CONFIDENTIAL. APPLICANT222S NAME Address Home Phone Type of Work DO ANY OTHER ADULTS LIVE WITH YOU IN YOUR HOME? No Yes Does this person contribute funds to pay towards the household expenses? No Yes If YES, please complete the following information: $ Amount per month this person contributes to pay household expenses. Your Income Previous 30 Day Income Previous 12 Month Income Gross income from wages Business income less expenses Unemployment income Child support, spousal support, alimony received Welfare or public assistance aid Other income * TOTAL *including any lottery winnings, gifts of cash, disability insurance, Social Security, retirement income, dividend income Number of children living in your home more than 100 days per year: Do you pay child support? No Yes If YES: How much per month? $ How much have you paid in the last 90 days? $ Do you have any savings accounts, certificates of deposit, money market accounts, stocks or bonds? (These funds may be taken into account in determining your eligibility for subsidy.) No Yes If YES, please state current value of (non- retirement) accounts and/or investments: $ By signing this application, I affirm that this is a true representation of my income, assets, and financial status as of this date, I understand this information may be made available upon request to the State of Vermont, and I have attached proof of my income. Signature of Applicant Date (over) Please attach copies of your last 3 pay stubs, or certificate from Department of Social Welfare, or a copy of last year222s tax return, and/or business profit and loss statement with expenses detailed, etc. 4/05SML American LegalNet, Inc. www.FormsWorkFlow.com VERMONT FAMILY COURT MEDIATION PROGRAM Subsidized Fee Scale March 2006 Subsidy is available for up to10 hours of mediation Household Income Fee (per person/per hour) Above $30,000 Full fee $30,000 $30 $27,000 $25 $24,000 $20 $21,000 $15 $18,000 $10 Subtract all child support and spousal support paid. Add all child support and spousal support received. Refer to chart for household income. Refer to chart for fee (this includes self and 1-2 minor children or other household dependent). For every two additional children living in your household 100 days or more per year, drop down one income category (two categories if there are 5 226 6 children, etc.) Both parents may claim the child(ren) as dependents if the children are in each household 30% or more of the time. If you choose to request a fee subsidy, you will be required to fill out an Application for Subsidy and attach documentation of your income. For Mediator Use Only Party222s fee per hour $ Case ID # American LegalNet, Inc. www.FormsWorkFlow.com