Form 228 APPLICATION TO PROCEED IN FORMA PAUPERIS Unit No. Circuit/County Type of Case Docket Number Name of Applicant Date of Birth Social Security Number Telephone Number (Day) Street Address City, State, Zip Code State of Vermont Court Names(s) of Dependents (People you Support) Relationship Applicant Cohabitant *** Applicant Cohabitant *** $ $ $ - $ IMPORTANT Total Number of Dependents (including applicant) Income Previous 30 Days Previous 12 Months Gross Income from Wages Telephone Number (Evening) Business Income less Expenses Unemployment Comp. Monthly Expenses Assets Real Estate Owned: Location Phone Rent Utilities/Fuel Food $ $ $ Motor Vehicles, Motorcycles, All Terrain Vehicles, Boats Clothing Fair Market Value - Outstanding Mortgage(s) = Net Worth Amount owed Year Make/Model Net Worth $ $ $ Public Assistance* $ Cash on Hand $ Total $ $B $A TOTAL ANNUAL INCOME $ $ *Public Assistance could include: TANF/Reach Up, SSI and General Assistance ** "Other" could include Disability Insurance and Social Security *** "Cohabitant": adult family members living with applicant Applicant's Employer: Name & Address $ Checking Account(s): Name of Bank and Account # (A+B) $ Savings Account: Name of Bank and Account # $ Cohabitant's Employer: Name & Address Other $ Other Cohabitant's Name No Relationship of Applicant to Cohabitant? Child Support Other Income** Yes Do you receive public assistance*? Do you cohabit *** with anyone? $ TOTAL ASSETS Medical Child Support Insurance: Home Health Auto Life Loan Payments: Motor Vehicles Home Mortgage Property Taxes Other Expenses Other Other $ TOTAL $ EXPENSES I request the Court waive filing fees and/or pay service fees in the above entitled matter because of my low income. I make the above answers UNDER PENALTY OF PERJURY. If at any time during the pendency of this action I become financially able to pay for the filing fees and/or service fees, I will do so. The above individual personally appeared before me and made oath to the truth of the above matters. Date Notary Public Signature of Applicant Date FINDINGS AND ORDER 1. The Applicant is Not a Financially Needy Person in that the applicant does have sufficient liquid assets, sufficient non-liquid assets which would provide collateral to borrow money, or sufficient income in excess of basic expenses to pay filing fees and service fees. Applicant's Request to Proceed In Forma Pauperis is hereby DENIED. You must pay $ to the court clerk within 30 days or the case will be dismissed. 2. The Applicant is a Financially Needy Person in that the applicant does not have sufficient liquid assets, sufficient non-liquid assets which would provide collateral to borrow money, or sufficient income in excess of basic expenses to pay filing fees or the service fees. Applicant's Request to Proceed in Forma Pauperis is hereby GRANTED. The ability to pay will be reassessed at the end of the case. 3. The Applicant is a Financially Needy Person. However, based on the financial statement, the applicant can pay the costs of service. The applicant is ordered to pay $ in service fees to the court clerk. to the sheriff. Respondent may be required to pay the remainder of service and filing fees and any additional service fees incurred during the pendency of this case. Date Court Clerk/Clerk Designee Notice to Applicant: You are advised that you have the right to appeal this order to the judge of this court. Your appeal must be filed in writing with the clerk of this court within 7 days of the date of this order. SML Rev. 11/06 Distribution: Court Applicant Service of Process Officer Respondent American LegalNet, Inc. www.FormsWorkflow.com