Financial Disclosure Affidavit {100-00127}

Financial Disclosure Affidavit 100-00127 Financial Disclosure Affidavit (04/2015) Page 1 of 2 State of Vermont Vermont Superior Court Division Unit Type of Case Docket Number Name: Others Living with You ( include adults and children) Address: Street: City, State, Zip: Telephone Number (Day) ( ) Telephone Number (Alternate) Date of Birth Mo Day Year / / Total Number in Household (including yourself ) EMPLOYMENT Are you employed? Y N Circle Y for yes or N for no Employer(s) Name(s) and Address(es) : If yes, fill in Name and Address of each employer INCOME EXPENSES Yes No Enter your monthly expenses Do you receive Public Assistance? ( including TANF/Reach UP; SSI, General Assistance) Y N Rent or Mortgage Pmt. $ Do any family members living with you receive public a ssistance Y N Electric Service $ Monthly Income d uring the previous year Food $ You Other Household Members Living With You Fuel (heat and/or gas) $ Gross Income from Wages $ $ Phone $ Self Employment/ Business Income (other than wages) $ $ Clothing $ Investment or Income from assets not included above $ $ Medical $ Unemployment Compensation $ $ Child Support $ Child Support $ $ Auto Loan Payments $ Public Assistance $ $ Property Taxes $ Other Income (Including Disability Insurance and Social Security) $ $ Insurance(Incl. Health, Auto, etc) $ Total Income $ $ Other Expenses: please specify $ Total Monthly Income ( Your income plus Household Members ) $ $ Is your income in the last 30 days significantly different from the previous year Y N $ If YES, please explain the circumstances on page 2. Total Expenses $ C ash Assets Other Assets Real Estate ( L ocation) Auto (Make , Model, Yr) Cash On Hand $ Checking Account $ Fair Market Value $ $ Savings Account $ Outstanding Mortgage $ $ Total Cash Assets $ Net Value $ $ American LegalNet, Inc. www.FormsWorkFlow.com Financial Disclosure Affidavit 100-00127 Financial Disclosure Affidavit (04/2015) Page 2 of 2 I have additional a ssets Y N If YES, please describe below Additional Assets: Vehicles Make, Model,Year Fair Market Value (FMV) Amount Owed Net value Real Property Description FMV Mortgage Net Value Other Assets e.g. tools, equipment, recreational vehicles, electronics, stocks, bonds, etc. Description FMV 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: Date Notary Public Date Other Employed Household Members Name of Household Member Name of Employer Change in Monthly 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.) American LegalNet, Inc. www.FormsWorkFlow.com