100-00508 226 Employer Disclosure (03/2019) Page 1 of 1 STATE OF VERMONT SUPERIOR COURT CIVIL DIVISION Unit Docket No.: Plaintiff(s) vs. Defendant (s) EMPLOYER DISCLOSURE NOTE: IF YOU SEND THIS FORM TO THE COURT BEFORE THE HEARING DATE, YOU DO NOT NEED TO COME TO THE HEARING. 1. Name of Company: 2. Do you pay the Defendant any wages, salary, commissions, Yes No bonuses or other payments for work he/she does for you/your company?.................. 3. Do you pay the Defendant any pension or retirement benefits?................................... 4. Will the Defendant be receiving payments from you in the future, even if he/she is not currently getting such payments?................................................. If so, when will he/she start receiving such payments? Date: 5. How much does the Defendant take home in payments from you/your company? (Choose One) $ per week $ every other week $ per month $ Other. Please explain: 6. If the payments vary, please state an average monthly amount and explain why they vary. $ average per month Explanation: 7. If you believe payments will change in the future, please explain: Yes No 8. Are there any voluntary deductions from the employee222s paycheck? 205205205205205205205205205.. If so, please list type and amount per pay period: I state under oath that the statements above are true. Dated Signature Signed and sworn to before me: Date Signature of Notary Public Expiration Date American LegalNet, Inc. www.FormsWorkFlow.com