Fillable APPLICATION FOR APPOINTMENT OF COUNSEL (Child Support Contempt) (Vermont Judiciary)

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APPLICATION FOR APPOINTMENT OF COUNSEL (Child Support Contempt) (Vermont Judiciary)

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APPLICATION FOR APPOINTMENT OF COUNSEL
(Child Support Contempt)
400-00229 - Application for Appointment of Counsel (Child Support Contempt) (04/2018) Page 1 of 2
State of Vermont
Vermont Superior Court
Division
Unit
Docket Number
FAMILY
Name
Last
Others Living with You (include adults and children)
Street Address
Town/City
State
Zip
Telephone Number
Date of Birth
Social Security Number
Total Number in Household (including Yourself)
EMPLOYMENT
Are you employed? Yes No
If Yes, fill in employer’s name(s) and
address(es)
Employer(s) Name(s) and Address(es) :
INCOME
EXPENSES
Yes
No
Enter your monthly household expenses
Do you receive Public Assistance?
(including TANF/Reach UP; SSI, General Assistance)
Do Any Family Members Living With You
Receive Public Assistance
Current Monthly Income
Rent or Mortgage Pmt.
$________________
You
Other Household
Members Living
With You
Electric Service
$________________
Gross Income from Wages
$____________
$_____________
Phone
$________________
Self Employment/Business Income
(other than wages)
$____________
$_____________
Fuel (heat and/or gas)
$________________
Unemployment Compensation
$____________
$_____________
Food
$________________
Child Support
$____________
$_____________
Clothing
$________________
Public Assistance
$____________
$_____________
Medical
$________________
Other Income (Including Disability
Insurance and Social Security)
$____________
$_____________
Child Support
$________________
Total Income
$
$
Auto Loan Payments
$________________
Total Monthly Income
(Your income plus Household members)
$
Property Taxes
$________________
Total Income in the past 12
months
$
Insurance (Incl. Health, Auto, etc.)
$________________
Is your income in the last 30 days significantly different
from your monthly income during the previous year
Yes
No
Other Expenses
$________________
If YES, please explain the circumstances on the next page.
Total Expenses
$
Cash Assets
Cash On Hand
$__________
Checking Account
$__________
Savings Account
$__________
Total Cash Assets
$__________
Additional Assets:
I have additional assets: Yes No
If Yes, describe them below
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
Use additional sheets as
necessary.
$
$
$
APPLICATION FOR APPOINTMENT OF COUNSEL
(Child Support Contempt)
400-00229 - Application for Appointment of Counsel (Child Support Contempt) (04/2018) Page 2 of 2
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 the reasons for the change.
My income last year (past 12 months) was
$
The income from other household members last year was:
$
The reason for the change is: (This section must be filled out if you have a change in income.)
I request the Court appoint an attorney for me in this case because of my low income. I further state that all of my
answers are true to the best of my knowledge and belief, UNDER PENALTY OF PERJURY.
Signed and sworn before me:
Notary Public
Date
Applicant Signature
Date
DETERMINATION OF FINANCIAL ELIGIBILITY
The Application is DENIED
The gross income of the applicant and cohabiting family members is greater than 150% of
the poverty line, AND welfare aid does not constitute a major portion of subsistence of the
applicant and cohabiting family members, AND the applicant is able to pay for an attorney
without expending income or liquid resources necessary for the maintenance of the applicant
and all dependents.
The Application is GRANTED
Welfare aid constitutes a major portion of subsistence of the applicant and cohabitating family
members. OR
The gross income of the applicant and cohabiting family members is at or below 150% of the
poverty income guidelines. OR
Applicant is unable to pay for an attorney without expending income or liquid resources necessary
for the maintenance of the applicant and all dependents.
☐ Counsel is assigned.
Signature of Clerk or Designee
Date
NOTICE OF RIGHT TO APPEAL: You have the right to appeal this order to the Judge of this
Court. Your appeal must be filed in writing with the clerk of this court within 7 days of the date of
this order.
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APPLICATION FOR APPOINTMENT OF COUNSEL (Child Support Contempt) (Vermont Judiciary)

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Completed 30 July 2020

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