Form 228J VERMONT JUDICIAL BUREAU 82 RAILROAD ROW PO BOX 607 WHITE RIVER JCT, VT 05001 802-295-8869 FINANCIAL AFFIDAVIT VERMONT CIVIL VIOLATION COMPLAINT(S): Court Unit No. Circuit/County Date of Birth Type of Case Social Security Number Docket Number Telephone Number (Day) State of Vermont Name of Applicant Street Address City, State, Zip Code Telephone Number (Evening) Names(s) of Dependents (People you Support) Relationship Total Number of Dependents (including applicant) IMPORTANT Do you receive welfare aid*? Yes No Income Previous 30 Days Previous 12 Months Applicant Applicant Assets Real Estate Owned: Location Fair Market Value Outstanding Mortgage(s) = Net Worth Monthly Expenses Phone Gross Income from Wages Business Income less Expenses Unemployment Comp. Child Support Welfare Aid * Other Income ** Total $ $ $ Rent Utilities/Fuel Food $ $ $ Motor Vehicles, Motorcycles, All Terrain Vehicles, Boats Clothing Year Make/Model Amount owed Net Worth Medical $ $ $ Cash on Hand $ $ $ Checking Account(s): Name of Bank and Account # TOTAL ANNUAL INCOME � Welfare Aid could Include; TANF/Reach up, SSI and General Assistance ** Other could include Disability Insurance and Social Security and any other source of Income Applicants Employer: Name & Address Savings Account: Name of Bank and Account # $ $ Other Other $ $ TOTAL ASSETS $ Child Support Insurance: Home Health Auto Life Loan Payments: Motor Vehicles Home Mortgage Property Taxes Other Expenses Other Other TOTAL $ EXPENSES I MAKE THE ABOVE ANSWERS UNDER PENALTY OF PERJURY. I FURTHER UNDERSTAND THAT THE COURT WILL USE THIS INFORMATION TO DETERMINE MY ABILITY TO SATISFY OUTSTANDING JUDGMENT DUE THE COURT. Defendant Signature Date The above individual personally appeared before me and made oath to the truth of the above information. Signature Notary Public Date Printed Name of Notary Public SML Rev. 8/06 Distribution: Court Applicant Service of Process Officer Respondent American LegalNet, Inc. www.FormsWorkFlow.com