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400 00813A 1 0 (Vermont Judiciary)

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400-00813A - Financial Affidavit (03/2019) Page 1 of 11
STATE OF VERMONT
SUPERIOR COURT
FAMILY DIVISION
Unit
Docket No.
Plaintiff Name
DOB
V.
Defendant Name
DOB
FINANCIAL AFFIDAVIT
(400-813A)
I am: ☐ Plaintiff ☐ Defendant ☐ Other: _____________________
Name
Mailing Address (if different from Street Address)
Town/City State Zip
Phone Number (evening)
Email Address
INSTRUCTIONS: You
are
required
to
complete and
file the
813A
if-
1.
You are
a
party
in a
newly filed divorce, civil union dissolution, legal separation, annulment
or
parentage action
and
you and
the other party have minor children;
OR
2.
You
or
the other party are seeking
to
modify
a
previously issued order regarding child support
or
spousal
maintenance (alimony);
OR
3.
You are the person required
to
pay support, and
an
enforcement action has been filed against you;
OR
4. Y
our child
is in
the custody
of
the Department
of
Children and Families and support has been requested
of
you;
OR
5.
You are ordered by the Court
to
complete and file this form
or
the other party requests that you fill out the form
as
part of the
discovery
process.
DEADLINE FOR FILING: This form must
be
filed with
the
court before
or at
your first case manager's conference.
If
no
conference
is
scheduled
it
must be filed
at
least seven (7) days before your first scheduled court
hearing.
YOU
MUST SEND
A
COPY
OF
YOUR COMPLETED FORM
TO THE
OTHER PARTY
AT THE
SAME
TIME YOU FILE IT
WITH
THE
COURT.
When you have completed the form and filled
in
all the required information, you must sign the Affirmation section below and have
your signature
notarized.
AFFIRMATION
I have read and filled in all the
information
requested.
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.
_____________________________________________________________
Sworn
to
me
on
__________
__________________________________
My Commission Expires: ___________
Signature of person making
affidavit
Signature of Notary Public
400-00813A - Financial Affidavit (03/2019) Page 2 of 11
SECTION I
-
INCOME
EMPLOYER NAME and ADDRESS
SECOND EMPLOYER
I am
self-employed
(sole
proprietor, partnership,
d/b/a) as a
I
am
not
currently
employed
because
A. MONTHLY GROSS INCOME FROM EMPLOYMENT - Income before any deductions for payroll taxes or benefits. (If your
income varies throughout the year, calculate your annual income and divide by twelve to get your monthly income in each
category
below.)
To calculate MONTHLY amounts from paychecks:
If you are paid weekly, multiply average weekly pay by 4.333.
If you are paid every other week, multiply average bi-weekly pay by 2.165
If you are paid twice a month, multiply average semi-monthly pay by 2
ATTACH 4 MOST RECENT PAY CHECK STUBS.
1. SALARY OR
WAGES
I have included overtime ☐ Yes ☐ No
2. TIPS, COMMISSIONS, BONUSES, ROYALTIES
3. SELF EMPLOYMENT INCOME
(Complete Self
Employment
Attachment on page 11 or attach IRS
SCHEDULE
C from tax filing)
4. PERSONAL EXPENSES PAID BY
EMPLOYER
(for
example:
cell phone, car, housing
allowance,
meals, military allowances)
Total Income from Employment
B. OTHER SOURCES OF INCOME (Indicate Monthly
Amount)
1. RENTAL INCOME
(Complete Rental Income Attachment on page 10 or attach IRS
SCHEDULE
E from tax filing)
2.
RETIREMENT/PENSIONS
3. UNEMPLOYMENT INSURANCE
BENEFITS
4. WORKER'S
COMPENSATION
and/or
DISABILITY
INSURANCE
5. SOCIAL SECURITY BENEFITS (Specify type
)
6. VETERANS BENEFITS (VA)
7. INTEREST OR DIVIDEND
INCOME
8. TRUST OR ANNUITY INCOME
9. GIFTS OR PRIZE MONEY (Including lottery winnings)
10. SPOUSAL
MAINTENANCE
(Alimony)
(From
the
other party
in this action)
11.
SPOUSAL MAINTENANCE
(Alimony)
(From
a
person
not a party in this action)
12. OTHER: Please
specify
(For example, capital
gains)
Total
Income
from
Other
Sources
TOTAL MONTHLY INCOME
(Employment and Other Sources)
400-00813A - Financial Affidavit (03/2019) Page 3 of 11
SECTION II - PUBLIC
BENEFITS
DO YOU RECEIVE PUBLIC BENEFITS?
☐
Yes
☐
No
If
yes, please check all boxes that apply and indicate dollar amount, where applicable
☐ Reach Up, RUFA, TANF __________ ☐ General Assistance __________ ☐ SSI __________
☐ Dr. Dynasaur/Blue First ☐ Medicaid/Medicare ☐ VHAP
☐ Fuel Assistance __________ ☐ Food Stamps __________ ☐ Housing Assistance
SECTION III -
INCOME/EXPENSES
of MINOR
CHILDREN
''Minor Children
''
means children under 18 or children over the age
of
18 but still
in
high
school.
A.
LIST ALL MINOR CHILDREN YOU HAVE WITH THE OTHER
PARTY
NAME
Date
of Birth
Current Primary
Residence
B.
LIST ALL OTHER MINOR CHILDREN FOR WHOM YOU PROVIDE
SUPPORT
NAME
Date of
Birth
Relationship
to you
Current Primary
Residence
C. LIST ALL CHILDREN FOR WHOM YOU ARE ORDERED TO PAY CHILD
SUPPORT
NAME
Amount
Ordered
Amount
Paid
State/County
of Order
400-00813A - Financial Affidavit (03/2019) Page 4 of 11
D.
HEALTH INSURANCE AVAILABLE THROUGH YOUR
EMPLOYMENT:
You must complete this paragraph
if
you could get this kind
of
insurance through your job even
if your
children are not enrolled.
Check with your Payroll
or
Human Resources Department
to
obtain amount
of
your monthly payroll contribution
to
the
cost.
TOTAL MONTHLY FAMILY HEALTH INSURANCE COST TO EMPLOYEE
TOTAL
MONTHLY TWO PERSON COST TO
EMPLOYEE
TOTAL
MONTHLY
COST
FOR
SINGLE
PERSON
COVERAGE
TO
EMPLOYEE
ARE CHILDREN OF THIS ACTION ENROLLED IN YOUR
PLAN? Yes No
E.
YOUR CHILD CARE COSTS FOR CHILDREN OF THIS
RELATIONSHIP
(If monthly amounts change during the year, use total annual amount divided by
12)
TOTAL MONTHLY CHILD CARE COSTS (before subsidy)
SUBSIDY
OUT OF POCKET COSTS (Total costs minus
subsidy)
Transfer
out of
pocket costs
to
Page
9,
line 51.
F. YOUR EXTRAORDINARY EXPENSES FOR CHILDREN OF THIS
RELATIONSHIP
Type
of expense
Cost per
month
Child's Uninsured Medical
expenses
Child's Educational
Expenses
Child's Special Needs
Expenses
G. MONTHLY INCOME RECEIVED BY
A
CHILD OF THIS
RELATIONSHIP
INCOME
SOURCE
Child's
Name
Amount
1.
DISABILITY
BENEFITS
2.
SOCIAL SECURITY
BENEFITS
3. OTHER
Name
of
Parent
who
receives
the
child's
benefit:
400-00813A - Financial Affidavit (03/2019) Page 5 of 11
LOANS
A. Primary Residence Loans:
SECTION IV - LOANS AND
DEBTS
Type
of Loan
Lender
Balance
owed
Monthly
payment
Check
here if YOU
are making this
payment
1.
Primary
Residence
2.
Second
Mortgage
3.
Home
Equity
Total
Primary
Residence
Transfer Monthly Payment Total to Page 7, Line 1
B. Other Real Estate Loans - DO NOT include business or rental property loans
Property
Description
Lender
Balance
Owed
Monthly
Payment
Check
here if
YOU
are making this
payment
Total Other Real Estate
Transfer Monthly Payment Total to Page 8, Line 38
C. Vehicle Loans
Type
of Vehicle
(Year, Make,
Model)
Lender
Balance
Owed
Monthly
Payment
Check
here if
YOU
are making this
payment
Total Vehicle
Loans
Transfer Monthly Payment Total to Page 7, Line 14
$ 0.00
400-00813A - Financial Affidavit (03/2019) Page 6 of 11
D. Other
Loans
Type
of Loan
Lender
Balance
Owed
Monthly
payment
Check
here if
YOU
are
making
this payment
Personal
Loan
School/College
Loan
Other
Other
Total
DEBTS
A. Credit Card Debt
Transfer Monthly Payment Total
to
Page
8,
Line
38
Card Holder
Company
Balance
Owed
Monthly
payment
Check
here if
YOU
are making this
payment
Total
Transfer Monthly Payment Total to Page
8,
Line
43
B.
Other Debts (for example tax liens, hospital bills, collection
accounts)
Type
of Debt
Company/Entity
Owed
Balance
Due
Monthly
payment if
any
Check
here if
YOU
are making this
payment
Total
Transfer Monthly Payment Total to Page 8, Line 38
400-00813A - Financial Affidavit (03/2019) Page 7 of 11
SECTION V -
EXPENSES
MONTHLY EXPENSES:
List your monthly expenses. For those expenses paid other than monthly, take the annual amount and divide it by 12. If
amount paid changes from month to month, use the annual amount divided by 12.
HOUSEHOLD
EXPENSES-
Amount
paid
by
you
Amount
paid
by
someone else
Total
Household
1. Rent or Mortgages, including Home Equity Loans
2. Property Taxes
3. Home Owner's or Renter's Insurance
4. Electricity
5.
Telephone (Land and Cell
Phone)
6.
Water
7. Gas for home
8. Oil, Wood or other fuel not listed above
9.
Mowing, Plowing,
Trash
10. Groceries
11. Cable/Internet
12. Laundry/Dry Cleaning
13. Maintenance/repair
TOTAL
OF
HOUSEHOLD
EXPENSES
VEHICLE
EXPENSES
Amount
paid
by
you
Amount
paid
by
someone else
Total
Household
14. Total Vehicle Loans
15. Car Insurance
16. Gas
17. Maintenance/Repairs
18. Registration
TOTAL
VEHICLE
INSURANCE
EXPENSES
Amount paid by
you
Amount
paid
by
someone else
Total
Household
19. Life Insurance
20. Disability Insurance
21. Health Insurance
22. Dental/Vision
TOTAL
INSURANCE
$ 0.00
400-00813A - Financial Affidavit (03/2019) Page 8 of 11
YOUR PERSONAL
EXPENSES
Amount paid by
you
Amount
paid
by
someone
else
Total
23.
Uninsured Medical
Expenses
24. Clothing/Shoes
25. Toiletries/Cosmetics
26.
Meals/Snacks
eaten out
27. Hair Care
28.
Magazines, Newspapers,
Books, other reading material
29.
Tobacco
and
Alcohol
Products
30.
Veterinarian
and other pet expenses
31. Entertainment (movies, bowling, museums,
etc.)
32.
Gifts
for others
33. Charitable Contributions
34. Vacation
35. Union
Dues
36.
Monthly Contribution
to Savings
37.
Monthly Contribution
to
Retirement Funds (401K, IRA,
etc.)
38.
Monthly Loan
&
Debt Payments
(do not
include primary
residence loans, credit cards, or vehicle
payments)
39.
Expenses
for
Children living
with you but not of this
relationship
40. Court Ordered Child Support you pay for children of another
relationship.
41.
Court Ordered Spousal Maintenance (Alimony) you
pay
42.
Miscellaneous (please
list on a
separate sheet and
fill in total
here)
TOTAL PERSONAL
EXPENSES
CREDIT CARD
DEBT
Amount paid by
you
Amount paid
by
someone else
Total
43.
TOTAL Monthly Payments
on Credit Cards
Amount paid by
you
Amount paid
by
someone
else
Total
GRAND TOTAL
of
Household, Vehicle, Insurance
and Personal
Expenses and Credit Card Payments
400-00813A - Financial Affidavit (03/2019) Page 9 of 11
INCOME TAX
PAYMENTS
MONTHLY PAYROLL WITHHOLDING
OR
ESTIMATED
TAXES
44.
FEDERAL
45. FICA
46. MEDICARE
47.
STATE
OF VERMONT
48.
OTHER TAXES
WITHHELD/PAID
CHILDREN'S
EXPENSES
MONTHLY EXPENSES
FOR
CHILDREN
OF THIS
RELATIONSHIP PAID
BY YOU
49.
Clothing
and Shoes
50. Diapers
51. Out-of-Pocket Child Care Costs related to your employment
52. School
lunches
53. School
supplies
54. Fees/expenses for special activities (e.g., piano lessons,
sports)
55. Summer Camp
56.
Private School
Tuition
57.
Uninsured Medical/Dental
Expenses
58. Child
Support
you pay for your
children
of this relationship
59.
Miscellaneous: Please itemize
below.
Miscellaneous
1
Miscellaneous
2
Miscellaneous
3
Miscellaneous
4
TOTAL MONTHLY EXPENSES
FOR CHILDREN
400-00813A - Financial Affidavit (03/2019) Page 10 of 11
1. Cleaning and Maintenance
2. Commissions
3. Insurance
4. Legal and Other Professional Fees
5. Mortgage Interest Paid to Banks
6. Other Interest
7. Repairs
8. Supplies
9. Taxes
10. Utilities
11. Wages and Salaries
12. Other (please list)
a.
b.
C.
d.
13.
Depreciation
Expense
TOTAL ANNUAL
EXPENSES
(Add Lines 1 through
13)
TOTAL ANNUAL INCOME
(Line A minus Line B)
TOTAL MONTHLY INCOME
(Line C divided by 12)
RENTAL INCOME ATTACHMENT (Schedule
E) A.
ANNUAL RENT RECEIVED
B. ANNUAL RENTAL EXPENSES
Line
A
Enter this amount on
Page 2, B. Line 1,
Section I) of Form 813A
Line B
Line C
400-00813A - Financial Affidavit (03/2019) Page 11 of 11
A. MONTHLY GROSS RECEIPTS OR SALES
B. MONTHLY BUSINESS EXPENSES
1. Cost of goods sold and/or operation
14. Office Expenses & Supplies
2. Advertising
15. Laundry & Cleaning
3. Bad debts from sales or service
16. Pension and/or profit sharing plan
4. Auto Expense: Gas __________
17. Rent for leased business property
Insurance __________
Maintenance __________
Registration __________
18. Machinery or Equipment
19. Other Business Property
5. Commissions
20. Repairs
6. Depletion
21. Supplies
7. Depreciation
22. Taxes
8. Dues & Publications
23. Travel
9. Employee Benefit Program
24. Meals & Entertainment
10. Insurance (other than Health) (Specify)
a.
25. Utilities & Telephone
b.
26. Wages
11. Interest paid on Mortgage (to banks)
27. Other (List & Specify)
a.
12. Other Interest Payment (Specify)
b.
c
13. Legal & Professional Services
d.
e.
f.
g.
TOTAL MONTHLY BUSINESS EXPENSES
(Add Lines 1 through 27)
MONTHLY BUSINESS NET INCOME (Gross
Receipts/Sales minus Expenses)
Enter this amount on Page 2 A Line 3 (Section I) of Form 813A
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400 00813A 1 0 (Vermont Judiciary)

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Completed 30 July 2020

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