Fillable (400-00813S) FINANCIAL AFFIDAVIT Non-Divorce V. (Vermont Judiciary)

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(400-00813S) FINANCIAL AFFIDAVIT Non-Divorce V. (Vermont Judiciary)

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400-00813S – Financial Affidavit - Non-Divorce (03/2019) Page 1 of 3
STATE OF VERMONT
SUPERIOR COURT
FAMILY DIVISION
Unit
Docket No.
Plaintiff Name
DOB
V.
Defendant Name
DOB
FINANCIAL AFFIDAVIT
(400-00813S)
Non-Divorce
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
400-00813S
if-
1.
You are
a
party
in a
newly filed Parentage case;
OR
2.
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 A
ffidavit
Signature of Notary Public
400-00813S – Financial Affidavit - Non-Divorce (03/2019) Page 2 of 3
1. I am the ☐ Plaintiff ☐ Defendant ☐ Other_____________________________________
2. My employer’s name and address is:
______________________________________________
______________________________________________
☐ I am self-employed as a ___________________________________________________________________
☐ I am not currently employed because ________________________________________________________
3. My gross monthly income (before taxes and deductions) is as follows:
If you are paid weekly, multiply weekly amount by 4.333.
If you are paid every two weeks, multiply bi-weekly amount by 2.165.
If your income varies through the year, divide your annual income by 12.
Type of Income
Amount
Salary and Wages
☐
This includes overtime
$
Expenses Paid by Employer
$
Self-Employment
*If self-employed, must attach self-employment worksheet or IRS Schedule C
$
Unemployment Benefits
$
Social Security Benefits Type______________
$
Veteran’s Benefits
$
Spousal Maintenance/Alimony
☐
This is from the other party in this case
$
Worker’s Compensation or Disability Insurance
$
Other source(s) of income (tips, rental income, gifts, interest, retirement benefits,
etc. List below or attach separate sheet)
$
TOTAL GROSS MONTHLY INCOME
$
4. I receive cash public assistance. ☐ Yes ☐ No If yes, list type and monthly amount: $________________.
5. I have the following children not with the other party in this case:
Name Date of Birth Current Primary Residence Address
____________________________ _______________ ____________________________________
____________________________ _______________ ____________________________________
____________________________ _______________ ____________________________________
____________________________ _______________ ____________________________________
0.00
400-00813S – Financial Affidavit - Non-Divorce (03/2019) Page 3 of 3
6. I am court-ordered to pay the following monthly amounts:
Type
Amount Ordered
Amount Paid
Issuing Court
Child Support for other children
$
$
Spousal Maintenance/Alimony
☐ check if other party in this
case
$
$
Other (specify):
$
$
7. I ☐ do ☐ do not have health insurance available through my employer
(if available, complete the following):
A. Total Monthly Cost: Family Plan $___________ 2 Person Plan $______________ Single Plan $____________
B. The child(ren) in this case ☐ are ☐ are not enrolled in my health insurance plan.
8. I ☐ do ☐ do not have employment-related child care (day care/babysitting) costs for child(ren) in this case.
If amounts change during the year, use the yearly amount divided by 12 months.
Monthly Child Care Costs: $________ Monthly Child Care Subsidy $_________Out of Pocket Costs: $__________
9. Extraordinary Expenses for child(ren) in this case (for ongoing extraordinary educational, medical or other special
needs, specify type of expense and cost per month): _________________________________________________
____________________________________________________________________________________________
10. Monthly Income received by any child(ren) in this case
(specify child’s name, type of income [social security, disability, or
other], monthly amount, and person who receives the benefit on the child’s behalf)
:_____________________________
___________________________________________________________________________________________
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(400-00813S) FINANCIAL AFFIDAVIT Non-Divorce V. (Vermont Judiciary)

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Completed 30 July 2020

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