Fillable APPLICATION TO WAIVE FILING FEES AND SERVICE COSTS (Vermont Judiciary)

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APPLICATION TO WAIVE FILING FEES AND SERVICE COSTS (Vermont Judiciary)

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APPLICATION TO WAIVE FILING FEES AND SERVICE COSTS
Form 228 - IFP (11/2014) Page 1 of 2
State of Vermont
Vermont Superior Court
Division
Unit
Docket Number
Name
First
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
If all adults living with you receive public
assistance, it is not necessary to fill out the
Expenses section below.
Otherwise, 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
Other Assets
Real Estate (Location)
Auto (Make , Model, Yr)
Cash On Hand
$__________
______________________
______________________
Checking Account
$__________
Fair Market
Value
$_____________
$_______________
Savings Account
$__________
Outstanding
Mortgage
$_____________
$_______________
Total Cash Assets
$__________
Net Value
$_____________
$_______________
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 TO WAIVE FILING FEES AND SERVICE COSTS
Form 228 - IFP (11/2014) 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 waive filing fees and/or pay service fees 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 cohabitating 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 cohabitating family members, AND the applicant is able to pay the filing fee and
costs of service without expending income or liquid resources necessary for the maintenance
of the applicant and all dependents.
You must pay
$
to the court clerk within 30 days or the case will be dismissed.
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 cohabitating family members is at or below 150% of the poverty
income guidelines. OR
Applicant is unable to pay the entire filing fee and costs of service without expending income or liquid
resources necessary for the maintenance of the applicant and all dependents.
THE FILING FEES AND COSTS OF SERVICE ARE WAIVED.
The Application is GRANTED in part and DENIED in part
Applicant is a financially needy person; however, based on the financial statement, Applicant has the ability to
pay the costs of service without expending income or liquid resources necessary for the maintenance of the
applicant and all dependents.
THE FILING FEES ARE WAIVED. THE COSTS OF SERVICE ARE NOT WAIVED.
You must pay
$
In service fees to the clerk sheriff.
You must pay
$
to the court clerk within 30 days or the case will be dismissed.
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 TO WAIVE FILING FEES AND SERVICE COSTS (Vermont Judiciary)

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Completed 30 July 2020

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