HELPING CHILDREN COPE WITH DIVORCE PROGRAM APPLICATION FOR REDUCED FEE THIS INFORMATION IS USED TO DETERMINE QUALIFICATION FOR REDUCED FEE ONLY AND IS NOT KEPT CONFIDENTIAL. APPLICANT'S 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 Gross income from wages Business income less expenses Unemployment income Child support, spousal support, alimony received Welfare or public assistance aid Other income * Previous 12 Month Income TOTAL *including any lottery winnings, gifts of cash, disability insurance, Social Security, retirement income, dividend income 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, UNDER PENALTY OF PERJURY, 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. __________________________________ Signature of Applicant ______________ Date The above individual personally appeared before me and made oath to the truth of the above matters. __________________________________ Signature of Notary ______________ Date Applicant qualifies for fee of $30.00 Applicant qualifies for fee of $15.00 Applicant does not qualify for reduced fee, $75.00 fee required Fees must be paid before you will be considered registered for the course and prior to attendance. Form 228C __________________________________ Court Clerk/Clerk Designee ______________________ Date American LegalNet, Inc. www.FormsWorkFlow.com