CONFIDENTIAL VERMONT FAMILY COURT Page 1 FINANCIAL AFFIDAVIT - FORM 813 INSTRUCTION SHEET WHO IS REQUIRED TO FILL OUT THIS FORM? New Divorce or Parentage Actions: If you are a party (Plaintiff or Defendant) in a newly filed divorce, parentage or legal separation action or civil union dissolution, you are required to fill out a Financial Affidavit and file it with the Court. Post Judgment Action: If you are a party in a divorce, parentage action or civil union dissolution, in which a motion has been filed after the Final Order (Motion for Enforcement, Motion for Contempt or Motion for Modification) and the issues raised by the motion(s) involve changes in or enforcement of child support or spousal maintenance, you are required to fill out and file a Financial Affidavit. Juvenile Cases: If your child is in DCF custody, you may be required to fill out a Financial Affidavit so that your support obligation to the State of Vermont can be determined. WHAT SECTIONS DO I NEED TO FILL OUT? Sections I and II: General Information, Affirmation and Income EVERYONE must fill out Sections I and II Section III: Income and Expense Information Relating to Children You must fill out Section III if you have minor children in common with the other party. Section IV: Household Expenses and Expense related to Debts You must fill out Section IV if: 1. You or the other party has requested spousal maintenance, a modification of spousal maintenance or enforcement of spousal maintenance; or 2. You or the other parent has requested a deviation from the child support guidelines; or 3. You are self employed and child support needs to be established or modified; or 4. A motion to enforce payment of child support has been filed against you; or 5. The other side has requested this information as part of Discovery; or 6. The Court has ordered you to provide this information. Section V: Supplemental Affidavit of Property and Assets You must fill out Section V if: 1. You are a party in a newly filed divorce or civil union dissolution; or 2. You are requested to fill it out by the other party as part of Discovery; or 3. You are ordered to fill it out by the Court. Schedules C and E/Rental Income Affidavit and Self Employment Affidavit: If you own your own business you will also need to file a Schedule C. If you have rental income, you will need to file a Schedule E. If you filed an income tax return last year which included one of these schedule, you may use a copy of the IRS schedule you filed. Otherwise, you can obtain the 813 version of these schedules from the Family Court. American LegalNet, Inc. www.FormsWorkflow.com Page 2 WHAT IS AN AFFIRMATION? When you sign the Affirmation on the first page, you are stating that all the information you have given on the form is true and correct to the best of your knowledge. You are also acknowledging that you understand that there may be criminal penalties and sanctions if you lie. WHO IS ''THE OTHER PARTY"? You will find frequent references in the affidavit to ''the other party''. The other party is the person on the other side of this case. It could be your spouse, former spouse, the parent of your child, your partner or former partner. If you are the plaintiff, ''the other party'' is the defendant. If you are the defendant, ''the other party'' is the plaintiff. WHAT IF MY INCOME CHANGES OR IS SEASONAL? Many people have income which changes from week to week or month to month depending on a number of variables such as overtime, seasonal work, etc. If your income changes, you should give your average monthly income. You can figure out your average monthly income by taking your annual income and dividing it by 12 or by adding up your pay for the past several months and then dividing by the number of months you used. Please be sure to indicate in the margin or at the bottom of the page, how you did the calculation. WHAT IF THERE IS NOT ENOUGH SPACE ON THE FORM? The court is looking for the most complete list you can provide. Please put additional information which does not fit on the form on another sheet of paper and attach it. OTHER DEFINITIONS: ''Gross monthly income'' means income before taxes or any other deductions such as health insurance, union dues, retirement, etc. If you are paid weekly, multiply weekly gross pay by 4.333. If you are paid every two weeks, multiply gross pay by 2.165. If you are paid twice a month, multiply by 2. If you receive annual income, divide by 12. ''Children of this Relationship'' means a child either born to you and the other party or adopted by you and the other party. ''Duty to Support'' means that you have an obligation by law or court order to support this child. It includes your own children and your step-children. It does not include children of a boyfriend, girlfriend or roommate who live in the same household with you. ''Market Value'' is the amount you would receive for an item of personal property if you sold it today. It is not the purchase price of the item or the replacement value. ''Your Home'' means your primary residence. ''Equity'' means the market value minus the debt owed on that particular item of real or personal property (e.g. mortgage on a home, car loan on a car, etc.) American LegalNet, Inc. www.FormsWorkflow.com 813 Financial Affidavit Name: FAMILY COURT Page 3 DOCKET NO. V. Plaintiff Defendant FINANCIAL AFFIDAVIT - FORM 813 SECTION I - GENERAL INFORMATION AND AFFIRMATION Name: Date of Birth: Street Address: Telephone #: (day) Mailing Address: Telephone #: (evening) City, State, Zip: Type of Action Currently Pending in Family Court: (check all appropriate boxes) Initial Action(no final order) Divorce with minor children no minor children Post Judgment Action Child Support Modification Enforcement Spousal Maintenance Modification Enforcement Parental Rights and Responsibilities or Parent Child Contact Modification Enforcement Other Parentage Dissolution (Civil Union) with minor children no minor children AFFIRMATION State of Vermont County I have read and filled in all the information requested in the following sections and included all appropriate attachments: (check boxes which apply) Section II -Income Section IV - Expense Information Section III - Income/Expenses - Children Section V - Property and Assets Schedule C from tax return (attached) Schedule E from tax return (attached) Rental Income Attachment Self Employment Attachment I hereby affirm of my own knowledge that the facts and financial information I am stating are true and correct as of the date of this Affirmation and that I am not omitting any source or amount of income or other information requested on this form. I understand that any false information may constitute perjury by me. I also understand that if I fail to provide the required information or give misinformation, the judge may order sanctions against me. Signature of person making affidavit Sworn to me on Notary Public , 20 My Commission Expires: / /20 American LegalNet, Inc. www.FormsWorkflow.com Name: Page 4 813 Financial Affidavit SECTION II - INCOME Please check appropriate boxes: I am currently employed by someone else. The name(s) and address(es) of my employer(s) is/are: Employer Name and Address Second Employer Name and Address . I am self-employed (Include sole proprietorship, partnership, closely held corp., d/b/a, etc.) I am not currently employed because: A. Monthly Gross Income from Employment ''Gross" income means income before taxes or any other deductions. If you are paid weekly, multiply weekly gross pay by 4.333. If you are paid every two weeks, multiply gross pay by 2.165. If you are paid twice a month, multiply by 2. If you receive annual income, divide by 12. 1. Monthly Pre-Tax Salary or Wages (all salaried employment plus overtime) If not paid monthly, show calculation: $ X or = 2. Monthly Income from Tips, Commissions, Bonuses or Royalties 3. Income From Rental Property (Attach Rental Income Attachment or Tax Return Schedule E) 4. Monthly Income from Self Employment (Attach Self Employment Attachment (C) or Tax Return Schedule C) Yes 5. Does your employer pay any of your personal expenses (e.g. car )? No ; Enter monthly amount If yes, specify type of expense(s): B. Other Sources of Income (indicate monthly amount) 1. Retirement/Pension 2. Unemployment Insurance Benefits 3. Worker's Compensation and/or Disability Insurance Benefits 4. Social Security Benefits (specify type: ) 5. Veterans Benefits (VA) 6. Interest or Dividend Income 7. Trust or Annuity Income 8. Gifts or prize money (include lottery winnings) 9. Spousal Maintenance (alimony) from the other party in this action 10. Spousal Maintenance from a person who is not a party in this action 11. Other: (e.g. capital gains) please specify TOTAL MONTHLY INCOME C. Do you receive public benefits? Reach Up (RUFA; TANF)$ SSI$ Fuel Assistance $ Yes No If yes, check all applicable boxes Enter dollar amounts where indicated. Food Stamps $ General Assistance $ Medicaid/Medicare Dr. Dynasaur/Blue First VHAP Housing Assistance American LegalNet, Inc. www.FormsWorkflow.com Page 5 813 Financial Affidavit Name: SECTION III - INCOME/EXPENSES RELATED TO MINOR CHILDREN OF THIS RELATIONSHIP 1. List all minor children of this relationship (under 18 or over 18 but still in high school): Use extra page if necessary Name: Birth Date Grade Current Primary Residence 2. Number of Children from another relationship whom you have a duty to support: ''Duty to Support'': means that you have an obligation by law or court order to support this child. It includes your own children and your step-children. It does not include children of a boyfriend, girlfriend or roommate who live in the same household with you. 3. Monthly Cost of Health Insurance paid by you for children of this relationship Total Health Insurance Premium paid by you Subtract cost of premium without children Cost of premium related solely to children paid by you $ $ 4. Out of Pocket Child Care Expenses for children of this relationship Gross monthly child care costs Subtract Child Care Subsidy Total monthly out-of-pocket child care expenses $ $ 5. Extraordinary Monthly Expenses for children of this relationship Medical (include only uninsured expenses over $16.67 per month) Educational expenses (specify) Special needs expenses (specify) $ $ $ 6. Pre-Existing monthly child support obligation for children who are not of this relationship. Enter only amount you actually pay per month. $ 7. Monthly income received by a child of this relationship: 1. Disability benefits (Name of child-recipient: 2. Social Security (Name of child-recipient: $ ) $ ) 3. Other: (specify) $ Name of Parent who receives income for child: 8. Other Information related to child support: a. Do you own any real estate other than your home yes no If yes, enter total equity in real estate other than your home: b. Enter number of vehicles owned ; Total equity value of vehicles: c. Total value of all other assets which do not produce income, including personal property, checking accounts, boats, antiques, etc. $ $ $ American LegalNet, Inc. www.FormsWorkflow.com Name: Page 6 813 Financial Affidavit SECTION IV -EXPENSES You are required to fill out this section if: 1 . You or the other party has requested spousal maintenance, a modification of spousal maintenance or enforcement of spousal maintenance; or 2. You or the other party has requested a deviation from the child support guidelines; or 3. You are self employed and child support needs to be established or modified; or 4. A motion to enforce payment of child support has been filed against you; or 5. The other party has requested this information as part of Discovery; or 6. The Court has ordered you to provide this information. LOANS List all debts for which you are responsible (either solely or with another person) Type of Loan Lender Monthly Payment Balance Owed 1. Primary Residence 1st Mortgage 2. 2nd Mortgage 3. Home Equity Add monthly payments from lines 1, 2 and 3 and transfer total to Expense Sheet, Line 6 4. Other Mortgages (describe): a. b. Add monthly payments from lines 4a and 4b and transfer to Expense Sheet, Line 6 5. Vehicle Loan #1 6. Vehicle Loan #2 Add monthly payments for vehicle loans and transfer to Expense Sheet, Line 21 7. Personal Loan 8. School/College Loans 9. Other Loans: a. b. Add monthly payments from lines 7, 8, 9a, and 9b and transfer total to Expense Sheet, Line 40 CREDIT CARD DEBT List all credit card debts regardless of card holder. Indicate name(s) of card holder in left hand column. Holder Company Balance Due Monthly Payment Transfer combined monthly payments which you actually make to Expense Sheet, Line 62 American LegalNet, Inc. www.FormsWorkflow.com -- 813 Financial Affidavit Name: Page 7 MONTHLY EXPENSES Expenses Paid By You 1 Taxes: Federal Taxes 2 State Taxes 3 Social Security Taxes (FICA) 4 Medicare 5 Contribution(s) to retirement fund deducted by employer 6 $ Total Household* * If others contribute to your housing and grocery expenses, list total expense in this column Housing: Rent or Mortgage (Include mortgage payments and home equity) 7 Property Taxes 8 Insurance (home owner's or renter's) 9 Electricity 10 Telephone 11 Water 12 Gas for home 13 Oil, wood, or other fuel not listed above 14 Mowing, plowing and trash collection 15 Maintenance/ repair 16 Groceries (food, cleaning products, etc.) 17 Other Insurance: Life 18 Disability 19 Health and Dental 20 Vehicle Insurance 21 Vehicle: total contributions Add lines 6-16 in this column Total Car payment(s) (include lease payment) 22 Gas 23 Registration 24 Maintenance 25 Uninsured Medical Expenses for yourself: e.g. eye care, dental, mental health 26 Meals/snacks eaten out 27 Clothing and shoes for yourself 28 Laundry and Dry Cleaning 29 Toiletries and Cosmetics American LegalNet, Inc. www.FormsWorkflow.com 813 Financial Affidavit Name: 30 Hair care 31 Magazines, newspapers, books and other reading material 32 Tobacco and Alcohol Products 33 Veterinary and other pet expenses including pet food 34 Entertainment (include cable TV payment, video rentals, movies, etc) 35 Gifts for friends and family 36 Monthly contribution to retirement fund (IRA, 4011, etc.) 37 Monthly contribution to savings account 38 Charitable contributions (religious organizations, non profits, etc.) 39 Vacation 40 Monthly loan payments (from page 6) 41 Union dues 42 Court Ordered child support for child(ren) from another relationship 43 Expenses for children living with you but not of this relationship 44 Court ordered spousal maintenance (alimony) 45 Page 8 Miscellaneous (please list on a separate sheet and fill in total here) Total Monthly Expenses For Yourself 46 EXPENSES FOR CHILDREN OF THIS RELATIONSHIP 47 48 Clothing and shoes 49 Diapers 50 Out-of-pocket Child Care Expenses 51 School lunches 52 School supplies 53 Tuition/expenses for special activities (e.g. piano lessons, gymnastics, etc) 54 Summer camp 55 Private school tuition 56 College Fund contribution 57 Uninsured medical expenses 58 Court ordered child support for children of this relationship 59 Miscellaneous (please list on a separate sheet and fill in total here) 60 Total Monthly Expenses for Children 61 Total Monthly Expenses for Yourself (from line 46) 62 Total monthly credit card payments (from page 6) TOTAL MONTHLY EXPENSES American LegalNet, Inc. www.FormsWorkflow.com Name: Page 9 813 Financial Affidavit SECTION V - SUPPLEMENTAL AFFIDAVIT OF PROPERTY AND ASSETS You are required to fill out this section if1. You are a party in a newly filed divorce, legal separation or civil union dissolution; or 2. You are requested to fill it out by the other party as part of discovery; or 3. You are ordered to fill it out by the Court. You may exclude any sheet on which you have no property to list. Please indicate which property or asset list(s) you have included: A. Real Property I have listed all real property in which I or the other party have an interest Neither I nor the other party own any real property B. Personal Property I have listed all personal property in which I have an interest I do not own any of the items listed or any other personal property of significant value C. Vehicles I have listed all vehicles owned by myself or the other party Neither I nor the other party own a vehicle of any kind D. Investments I have listed all of my investments or investments of the other party Neither I nor the other party own any investments E. Bank Accounts I have listed all bank accounts in my name, the other party's name or joint names Neither I nor the other party own any bank accounts F. Retirement Accounts I have listed all retirement accounts in my name or the other party's name Neither I nor the other party own any retirement accounts G. Life Insurance Policies I have listed all life insurance policies in my name or the other party's name Neither I nor the other party own any life insurance policies H. Businesses I have listed all businesses in which I own an interest (other than as a shareholder) Neither I nor the other party own an interest in a business Have you or your spouse sold or conveyed any asset in the last 12 months, withdrawn funds from an account other than your regular checking or savings account (e.g. investment account, retirement account, etc.) aside from normal household activities? Yes No If yes, indicate the type of asset sold or conveyed or the account from which the withdrawal was made, and the amount of funds you obtained as a result of the transaction. If you withdrew funds or received funds as a result of the sale of an asset, indicate how the funds were spent or invested. American LegalNet, Inc. www.FormsWorkflow.com Name: Page 10 813 Financial Affidavit A. REAL PROPERTY List all real estate in which you or the other party own an interest regardless of title or possession. If you or the other party own only a partial interest, indicate percentage of interest. Description of Property Indicate Location Primary Residence (house, condo, mobile home, Mortgages, liens, Attachments Market Value Equity $ Value Minus Liens etc.) Real Estate Other than Primary Residence Second Home Camp Timeshare Unimproved Land Mobile Home (not used as primary residence) Commercial Property (Attach IRS Schedule E) Other: (describe any interest or % of interest in real estate not listed above) (The "Equity" column below needs to be self i calculated for "Other") I TOTAL VALUE OF REAL PROPERTY EXCLUDING PRIMARY RESIDENCE If You Receive Rent/Income From Any of The Above Described Properties, You Must Complete And Attach the 813 Rental Income Attachment or Schedule E from your tax return. Note: If you filed taxes in the previous year, you must file a copy of the Schedule E from your income tax return. Otherwise, you must use the 813 Rental Income Attachment which is available at the Family Court. American LegalNet, Inc. www.FormsWorkflow.com Name: Page 11 813 Financial Affidavit B. PERSONAL PROPERTY ITEM DESCRIPTION YOUR ITEMS Check ( ) if Item is in your possession Estimate Market Value As Defined Below OTHER PARTY Check ( ) if item is in other party's possession Estimate Market Value As Defined Below Jewelry Antiques Artwork Guns Coins/Stamps Tools Collectibles Piano/Musical Instruments China/Crystal/Silverware Appliances Electronics Furnishings Computers Other (describe ) Total Estimated Value of Personal Prop. If any of the items listed above are encumbered by any debts or loans, indicate in the space below which items, the balance owed on the debt and which party is currently making payments on the loan/debt. ''Market Value" is defined as the amount you could reasonably receive if you sold this item today. It is not the purchase price of the item or the replacement value of the item. American LegalNet, Inc. www.FormsWorkflow.com Name: Page 12 813 Financial Affidavit C. VEHICLES and BOATS LIST ALL VEHICLES REGARDLESS OF TITLE OR OWNERSHIP Indicate title holder in left column Title Holder Description of Vehicle Indicate make and year Car #1 Market Value 1 $ Equity Value - Liens Liens $ $ $ Car #2 Truck #1 Truck #2 Motorcycle #1 Motorcycle #2 RV Title Holder Other Vehicles and Boats Boat Snowmobile #1 Snowmobile #2 Camper (not motorized) Tractor/Riding Mower Plane ATV Additional vehicles not listed above 1 '''Market Value'' for motor vehicles is the retail value indicated in the NADA Blue Book or other similar price guide. American LegalNet, Inc. www.FormsWorkflow.com 813 Financial Affidavit Name: Page 13 D. INVESTMENTS List all investments regardless of ownership or title Owner Description (e.g. company, bank, name of fund, etc) Type Number of Shares Market Value E. BANK ACCOUNTS and CASH Owner Type of Account Bank Current Balance Checking Account #1 Checking Account #2 Savings Account #1 Savings Account #2 Money Market Account #1 Money Market Account #2 Funds/Cash held by another for your benefit Cash in your possession Other Accounts not listed above American LegalNet, Inc. www.FormsWorkflow.com Name: Page 14 813 Financial Affidavit F. RETIREMENT ACCOUNTS/PENSIONS List all retirement accounts. Indicate account holder in left hand column. Owner Account Type Financial Institution Value IRA #1 IRA #2 401 (k) 403 (b) TIAA - CREF Keough TDSP TSA Profit Sharing Savings & Securities Deferred Compensation Other Pension Administrator Pension Plans Value Defined Benefit Defined Contribution Target Benefit Military Pension SEP Owner Other Retirement Accounts (Please describe) Value American LegalNet, Inc. www.FormsWorkflow.com Name: 813 Financial Affidavit Page 15 G. LIFE INSURANCE POLICIES List all life insurance policies regardless of ownership Name of Insured Beneficiary Company Face Value Loan Balance Cash Value H. BUSINESS OWNERSHIP List all businesses in which you and/or the other party own an interest. Owner Name of Business, Type of Business Activity and Legal % of your Structure (e.g. Sole Proprietorship, Partnership, Sub Chapter S, Interest etc. Date of Most Fair Market Recent Value Valuation You Must Attach an 813 Self Employment Attachment or a Schedule C from your Tax Return for Any Business from Which You Earn or Receive Income, Profits, Distributions, in-Kind Income, Etc. Note: If you filed taxes in the previous year, you must file a copy of the Schedule C from your income tax return. Otherwise, you must use the 813 Self Employment Attachment which is available at the Family Court. American LegalNet, Inc. www.FormsWorkflow.com Name: 813 Rental Income Attachment Page 16 RENTAL INCOME ATTACHMENT (Schedule E) A. ANNUAL RENT RECEIVED Line A B. ANNUAL RENTAL EXPENSES 1. Advertising 2. Auto and Travel 3. Cleaning and Maintenance 4. Commissions 5. Insurance 6. Legal and Other Professional Fees 7. Mortgage Interest Paid to Banks 8. Other Interest 9. Repairs 10. Supplies 11. Taxes 12. Utilities 13. Wages and Salaries 14. Other (please list) a. b. c. d. 15. Depreciation Expense TOTAL ANNUAL EXPENSES (Add Lines 1 through 15) Line B TOTAL ANNUAL INCOME (Line A minus Line B) Line C Enter this Amount on Page 4, Line A. 3., TOTAL MONTHLY INCOME (Line C divided by 12) Section II of Form 813 American LegalNet, Inc. www.FormsWorkflow.com Page 17 813 Self Employment Attachment Name: SELF EMPLOYMENT ATTACHMENT (Schedule C) A. MONTHLY GROSS RECEIPTS OR SALES $ B. MONTHLY BUSINESS EXPENSES 1. Cost of goods sold and/ or operation 14. Office Expenses and Supplies 2. Advertising 15. Laundry and Cleaning 3. Bad debts from sales or service 4. Auto: Gas 16. Pension and/or profit sharing plan 17. Rent for leased business property 18. Machinery or Equipment Insurance 19. Other Business Property Maintenance 20. Repairs Registration Total Auto Expenses 5. Commissions 21. Supplies 22. Taxes 23. Travel 6. Depletion 24. Meals and Entertainment 7. Depreciation 25. Utilities and Telephone 8. Dues and Publications 26. Wages 27. Other List and Specify a. 9. Employee Benefit Program 10. Insurance (other than health) Specify: a. b. b. c. 11. Interest paid on Mortgage (to banks) d. e. 12. Other Interest Payment (Specify f. 13. Legal and Professional Services g. TOTAL MONTHLY BUSINESS EXPENSES Add Lines 1 through 27 (Gross Receipts/Sales minus Expenses) MONTHLY BUSINESS INCOME Enter this amount on page 4 titled ''Section II - Income'' in Section A. Monthly Gross Income from Employment, line 4 of Form 813. $ $ American LegalNet, Inc. www.FormsWorkflow.com