400-00813A - Financial Affidavit Page 1 of 11 STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Docket No. Plaintiff Name DOB V. Defendant Name DOB FINANCIAL AFFIDAVIT ( 400 - 813A) I am: Plaintiff Defendant Other: Name Street Address Mailing Address (if different from Street Address ) Town/City State Zip Town/City State Zip Phone Number (day) Phone Number (evening) Email Address INSTRUCTIONS: You are required to complete and file the 813A if - 1. You are a party in a newly filed divorce, civil union dissolution, legal separation, annulment or parentage action and you and the other party have minor children; OR 2. You or the other party are seeking to modify a previously issued order regarding child support or spousal maintenance (alimony); OR 3. You are the person required to pay support, and an enforcement action has been filed against you; OR 4. Y our child is in the custody of the Department of Children and Families and support has been requested of you; OR 5. You are ordered by the Court to complete and file this form or the other party requests that you fill out the form as part of the discovery process. DEADLINE FOR FILING: This form must be filed with the court before or at your first case manager's conference. If no conference is scheduled it must be filed at least days before your first scheduled court hearing. YOU MUST SEND A COPY OF YOUR COMPLETED FORM TO THE OTHER PARTY AT THE SAME TIME YOU FILE IT WITH THE COURT. When you have completed the form and filled in all the required information, you must sign the Affirmation section below and have your signature notarized. AFFIRMATION I have read and filled in all the information requested. I hereby affirm of my own knowledge that the facts and financial information I have stated 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, t he judge may order sanctions against me. Sworn to me on My Commission Expires: Signature of person making affidavit Signature of Notary Public American LegalNet, Inc. www.FormsWorkFlow.com 400-00813A - Financial Affidavit Page 2 of 11 SECTION I - INCOME EMPLOYER NAME and ADDRESS SECOND EMPLOYER I am self - employed (sole proprietor, partnership, d/b/a) as a I am not currently employed because A. MONTHLY GROSS INCOME FROM EMPLOYMENT - Income before any deductions for payroll taxes or benefits. (If your income varies throughout the year, calculate your annual income and divide by twelve to get your monthly income in each category below.) To calculate MONTHLY amounts from paychecks: If you are paid weekly, multiply average weekly pay by 4.333. If you are paid every other week, multiply average bi - weekly pay by 2.165 If you are paid twice a month, multiply average semi - monthly pay by 2 ATTACH 4 MOST RECENT PAY CHECK STUBS. 1. SALARY OR WAGES I have included overtime Yes No 2. TIPS, COMMISSIONS, BONUSES, ROYALTIES 3. SELF EMPLOYMENT INCOME (Complete Self Employment Attachment on page 11 or attach IRS SCHEDULE C from tax filing) 4. PERSONAL EXPENSES PAID BY EMPLOYER (for example: cell phone, car, housing allowance, meals, military allowances) Total Income from Employment B. OTHER SOURCES OF INCOME (Indicate Monthly Amount) 1. RENTAL INCOME (Complete Rental Income Attachment on page 10 or attach IRS SCHEDULE E from tax filing) 2. RETIREMENT/PENSIONS 3. UNEMPLOYMENT INSURANCE BENEFITS 4. WORKER'S COMPENSATION and/or DISABILITY INSURANCE 5. SOCIAL SECURITY BENEFITS (Specify type ) 6.VETERANS BENEFITS (VA) 7. INTEREST OR DIVIDEND INCOME 8. TRUST OR ANNUITY INCOME 9.GIFTS OR PRIZE MONEY (Including lottery winnings) 10. SPOUSAL MAINTENANCE (Alimony) (From the other party in this action) 11. SPOUSAL MAINTENANCE (Alimony) (From a person not a party in this action) 12. OTHER: Please specify (For example, capital gains) Total Income from Other Sources TOTAL MONTHLY INCOME (Employment and Other Sources) American LegalNet, Inc. www.FormsWorkFlow.com 400-00813A - Financial Affidavit Page 3 of 11 SECTION II - PUBLIC BENEFITS DO YOU RECEIVE PUBLIC BENEFITS? Yes No If yes, please check all boxes that apply and indicate doll ar amount, where applicable Reach Up, RUFA, TANF General Assistance SSI Dr. Dynasaur/Blue First Medicaid/Medicare VHAP Fuel Assistance Food Stamps Housing Assistance SECTION III - INCOME/EXPENSES of MINOR CHILDREN ''Minor Children '' means children under 18 or children over the age of 18 but still in high school. A. LIST ALL MINOR CHILDREN YOU HAVE WITH THE OTHER PARTY NAME Date of Birth Current Primary Residence B. LIST ALL OTHER MINOR CHILDREN FOR WHOM YOU PROVIDE SUPPORT NAME Date of Birth Relationship to you Current Primary Residence C. LIST ALL CHILDREN FOR WHOM YOU ARE ORDERED TO PAY CHILD SUPPORT NAME Amount Ordered Amount Paid State/County of Order American LegalNet, Inc. www.FormsWorkFlow.com 400-00813A - Financial Affidavit Page 4 of 11 D. HEALTH INSURANCE AVAILABLE THROUGH YOUR EMPLOYMENT: You must complete this paragraph if you could get this kind of insurance through your job even if your children are not enrolled. Check with your Payroll or Human Resources Department to obtain amount of your monthly payroll contribution to the cost. TOTAL MONTHLY FAMILY HEALTH INSURANCE COST TO EMPLOYEE TOTAL MONTHLY TWO PERSON COST TO EMPLOYEE TOTAL MONTHLY COST FOR SINGLE PERSON COVERAGE TO EMPLOYEE ARE CHILDREN OF THIS ACTION ENROLLED IN YOUR PLAN? Yes No E. YOUR CHILD CARE COSTS FOR CHILDREN OF THIS RELATIONSHIP (If monthly amounts change during the year, use total annual amount divided by 12) TOTAL MONTHLY CHILD CARE COSTS (before subsidy) TOTAL MONTHLY CHILD CARE SUBSIDY OUT OF POCKET COSTS (Total costs minus subsidy) Transfer out of pocket costs to Page 9 , line 51 . F. YOUR EXTRAORDINARY EXPENSES FOR CHILDREN OF THIS RELATIONSHIP Type of expense Cost per month Child's Uninsured Medical expenses Child's Educational Expenses Child's Special Needs Expenses G. MONTHLY INCOME RECEIVED BY A CHILD OF THIS RELATIONSHIP INCOME SOURCE Child's Name Amount 1. DISABILITY BENEFITS 2. SOCIAL SECURITY BENEFITS 3. OTHER Name of Parent who receives the child's benefit: American LegalNet, Inc. www.FormsWorkFlow.com 400-00813A - Financial Affidavit Page 5 of 11 LOANS A. Primary Residence Loans: SECTION IV - LOANS AND DEBTS Type of Loan Lender Balance owed Monthly payment Check here if YOU are making this payment 1. Primary Residence 2. Second Mortgage 3. Home Equity Total Primary Residence Transfer Monthly Payment Total to Page 7, Line 1 B. Other Real Estate Loans - DO NOT include business or rental property loans Property Description Lender Balance Owed Monthly Payment Check here if YOU are making this payment Total Other Real Estate Transfer Monthly Payment Total to Page 8, Line 38 C. V ehicle Loans Type of Vehicle (Year, Make, Model) Lender Balance Owed Monthly Payment Check here if YOU are making this payment Total Vehicle Loans Transfer Monthly Payment Total to Page 7, Line 14 American LegalNet, Inc. www.FormsWorkFlow.com 400-00813A - Financial Affidavit Page 6 of 11 D. Other Loans Type of Loan Lender Balance Owed Monthly payment Check here if YOU are making this payment Personal Loan School/College Loan Other Other Total DEBTS A. Credit Card Debt Transfer Monthly Payment Total to Page 8, Line 38 Card Holder Company Balance Owed Monthly payment Check here if YOU are making this payment Total Transfer Monthly Payment Total to Page 8, Line 43 B. Other Debts (for example tax liens, hospital bills, collection accounts) Type of Debt Company/Entity Owed Balance Due Monthly payment if any Check here if YOU are making this payment Total Transfer Monthly Payment Total to Page 8, Line 38 American LegalNet, Inc. www.FormsWorkFlow.com 400-00813A - Financial Affidavit Page 7 of 11 SECTION V - EXPENSES MONTHLY EXPENSES: List your monthly expenses. For those expenses paid other than monthly, take the annual amount and divide it by 12. If amount paid changes from month to month, use the annual amount divide