Financial Disclosure Affidavit State of Vermont Vermont Superior Court Division Unit Type of Case Docket Number Name: Street: Others Living with You (include adults and children) Address: City, State, Zip: Telephone Number (Day) Telephone Number (Alternate) ( ) Mo Day Year Date of Birth / / Total Number in Household (including yourself) EMPLOYMENT Are you employed? Y N Circle Y for yes or N for no If yes, fill in Name and Address of each employer Employer(s) Name(s) and Address(es) : INCOME Yes No N EXPENSES Enter your household's monthly expenses Rent or Mortgage Pmt. Electric Service Food Fuel (heat and/or gas) Phone Clothing Medical Child Support Auto Loan Payments Property Taxes Insurance(Incl. Health, Auto, etc) Other Expenses: please specify $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ Y N $________________ Y Do you receive Public Assistance? (including TANF/Reach UP; SSI, General Assistance) Do any family members living with you receive public assistance Y N Monthly Income during the previous year You Gross Income from Wages Self Employment/Business Income (other than wages) Investment or Income from assets not included above 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 ) Is your income in the last 30 days significantly different from the previous year If YES, please explain the circumstances on page 2. Total Expenses Real Estate (Location) $ Auto (Make , Model, Yr) ______________________ Cash Assets Cash On Hand Checking Account Savings Account $__________ $__________ $__________ $__________ Fair Market Value Outstanding Mortgage Other Assets ______________________ $_____________ $_____________ $_____________ $_______________ $_______________ $_______________ Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Total Cash Assets Net Value 100-00127 ­ Financial Disclosure Affidavit (04/2015) Financial Disclosure Affidavit I have additional assets Y N If YES, please describe below Additional Assets: Vehicles Make, Model,Year 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 Other Employed Household Members Name of Household Member 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 your current monthly income and the reasons why it changed. My current monthly income is: $ My current household income is: $ The reason for the change is: (This section must be filled out if you have a change in income.) 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, the judge may order sanctions against me. Signed and sworn before me: Notary Public Date Defendant's Signature Date 100-00127 ­ Financial Disclosure Affidavit (04/2015) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com