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APPLICATION TO WAIVE FILING FEES AND SERVICE COSTS (11/2014) Page 1 of 2 State of Vermont Name Others Living with You Telephone Number Date of Birth Social Security Number EMPLOYMENT Y es N o INCOME EXPENSES Yes No If all adults living with you receive public assistance, it is not necessary to fill out the Expenses section below. monthly Do you receive Public Assistance? Current Monthly Income Total Monthly Income Total Income in the past 12 months I s your income in the last 30 days s ignificantly different from your monthly income during the previous year Y es N o Total Expenses C ash Assets Other Assets Real Estate Auto Cash On Hand $ Checking Account $ Savings Account $ Total Cash Assets Net Value Additional Assets: I have additional assets: Y es N o American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION TO WAIVE FILING FEES AND SERVICE COSTS (11/2014) Page 2 of 2 Change in Monthly Income: The reason for the change is: Signed and sworn before me: Notary Public Date Applicant Signature Date DETERMINATION OF FINANCIAL ELIGIBILITY DENIED You must pay $ t o the court clerk within 30 days or the case will be d ismissed. GRANTED THE FILING FEES AND COSTS OF SERVICE ARE WAIVED. GRANTED DENIED THE FI LING FEES ARE WAIVED. THE COSTS OF SERVICE ARE NOT WAIVED. You must pay In service fees to the clerk sheriff. You must pay $ to the court clerk within 30 days or the case will be dismissed. Signature of Clerk or Designee Date NOTICE OF RIGHT TO APPEAL: appeal American LegalNet, Inc. www.FormsWorkFlow.com