APPLICATION TO WAIVE FILING FEES AND SERVICE COSTS State of Vermont Division Unit Docket Number Vermont Superior Court First Last Name Street Address Town/City Others Living with You (include adults and children) State Zip Telephone Number Date of Birth Social Security Number Total Number in Household (including Yourself) EMPLOYMENT Are you employed? Yes No Employer(s) Name(s) and Address(es) : If Yes, fill in employer's name(s) and address(es) INCOME Yes No EXPENSES If all adults living with you receive public assistance, it is not necessary to fill out the Expenses section below. Otherwise, enter your monthly household expenses Rent or Mortgage Pmt. Electric Service Phone Fuel (heat and/or gas) Food Clothing Medical Child Support Auto Loan Payments Property Taxes Insurance(Incl. Health, Auto, etc) Yes No Other Expenses $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ Do you receive Public Assistance? (including TANF/Reach UP; SSI, General Assistance) Do Any Family Members Living With You Receive Public Assistance Current Monthly Income You Gross Income from Wages Self Employment/Business Income (other than wages) Unemployment Compensation Child Support Public Assistance Other Income (Including Disability Insurance and Social Security) Other Household Members Living With You $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $____________ $____________ $____________ $____________ $____________ $____________ Total Income Total Monthly Income $ $ $ $ (Your income plus Household members) Total Income in the past 12 months Is your income in the last 30 days significantly different from your monthly income during the previous year If YES, please explain the circumstances on the next page. Total Expenses Real Estate (Location) Fair Market Value Outstanding Mortgage $ Auto (Make , Model, Yr) ______________________ Cash Assets Cash On Hand Checking Account Savings Account $__________ $__________ $__________ $__________ Other Assets ______________________ $_____________ $_____________ $_____________ $_______________ $_______________ $_______________ Total Cash Assets Net Value Additional Assets: I have additional assets: Yes Vehicles Make, Model, Year No If Yes, describe them below Fair Market Value (FMV) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Amount Owed $ $ $ $ $ $ Net value Real Property Other Assets e.g. tools, equipment, recreational vehicles, electronics, stocks, bonds, etc. Description FMV Mortgage Net Value Description FMV Use additional sheets as necessary. American LegalNet, Inc. www.FormsWorkFlow.com Form 228 - IFP (11/2014) Page 1 of 2 Other Employed Household Members Name of Household Member APPLICATION TO WAIVE FILING FEES AND SERVICE COSTS Name of Employer Employer's Address Change in Monthly Income: If your current monthly income is significantly different from last year's income, please describe the reasons for the change. My income last year (past 12 months) was $ The income from other household members last year was: $ The reason for the change is: (This section must be filled out if you have a change in income.) I request the Court waive filing fees and/or pay service fees in this case because of my low income. I further state that all of my answers are true to the best of my knowledge and belief, UNDER PENALTY OF PERJURY. Signed and sworn before me: Notary Public Date Applicant Signature Date DETERMINATION OF FINANCIAL ELIGIBILITY The Application is DENIED The gross income of the applicant and cohabitating family members is greater than 150% of the poverty line, AND welfare aid does not constitute a major portion of subsistence of the applicant and cohabitating family members, AND the applicant is able to pay the filing fee and costs of service without expending income or liquid resources necessary for the maintenance of the applicant and all dependents. to the court clerk within 30 days or the case will be dismissed. You must pay $ The Application is GRANTED Welfare aid constitutes a major portion of subsistence of the applicant and cohabitating family members. The gross income of the applicant and cohabitating family members is at or below 150% of the poverty income guidelines. OR Applicant is unable to pay the entire filing fee and costs of service without expending income or liquid resources necessary for the maintenance of the applicant and all dependents. OR THE FILING FEES AND COSTS OF SERVICE ARE WAIVED. The Application is GRANTED in part and DENIED in part Applicant is a financially needy person; however, based on the financial statement, Applicant has the ability to pay the costs of service without expending income or liquid resources necessary for the maintenance of the applicant and all dependents. THE FILING FEES ARE WAIVED. THE COSTS OF SERVICE ARE NOT WAIVED. You must pay You must pay $ $ In service fees to the clerk sheriff. to the court clerk within 30 days or the case will be dismissed. Signature of Clerk or Designee Date NOTICE OF RIGHT TO APPEAL: 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. American LegalNet, Inc. www.FormsWorkFlow.com Form 228 - IFP (11/2014) Page 2 of 2