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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600-00228 – Application to Waive Filing Fees & Service Costs (08/2020) Page 1 of 3
STATE
OF
VERMONT
SUPERIOR COURT
Unit
Docket No.
APPLICATION TO WAIVE FILING FEES AND SERVICE COSTS
Name (First & Last) _____________________________________________________________________________
Street Address: _________________________________________________________________________________
City/State/Zip: ___________________________________________________________________________________________________
Mailing Address:
(if different from street address)________________________________________________________
Telephone Number: ________________ Date of Birth: ____________ Social Security #: _______________
Others Living with You (include adults & children)
____________________________ ____________________________ ____________________________
____________________________ ____________________________ ____________________________
Total Number Living in Household ____________________________
Employment
Are you employed? ☐ Yes ☐ No If Yes, list Employers’ Name & Address
Employer Name Employer Address
_________________________ ______________________________________________
_________________________ ______________________________________________
Income
Do you receive Public Assistance? ☐ Yes ☐ No
(
including TANF/Reach UP; SSI, General Assistance)
Your Current Monthly Income
Gross Income from Wages $__________
Unemployment Compensation $__________
Child Support $__________
Public Assistance $__________
Oher Income $__________
(including Disability Insurance & Social Security)
Self-E
mployment/Business Income $__________
(other than wages)
Total Monthly Income $_______________
Total Income in the past 12 months $_______________
Is your income in the last 30 days significantly different
from your monthly income during the previous year?
☐ Yes ☐ No
If Yes, please explain the circumstance on the next page.
Expenses
Enter your monthly household expenses
R
ent or Mortgage Payment $_____________
Electric Service $_____________
Phone $_____________
Fuel
(heat and/or gas) $_____________
Food $_____________
Clothing $_____________
Medical $_____________
Child Support $_____________
Auto Loan Payment $_____________
Property Taxes $_____________
Insurance
(health, auto, etc.) $_____________
Other Expenses $_____________
Total Expenses $_____________
600-00228 – Application to Waive Filing Fees & Service Costs (08/2020) Page 2 of 3
Cash Assets
Cash on Hand $_____________
Checking Account $_____________
Savings Account $_____________
Total Cash Assets $_____________
Real Estate Auto
(Location) (Make, Model, Year)
_______________ _______________
Fair Market $_____________ $_____________
Value Outstanding $_____________ $_____________
Mortgage $_____________ $_____________
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
(examples - tools,
equipment, recreational
vehicles, electronics,
stocks, bonds, etc.)
Description
FMV
Use additional sheets as necessary
Change in Monthly Income
If your current monthly income is significantly different from last year’s income, describe the reasons for the change.
My income last year (past 12 months) was $__________
The reason for the change is: __________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________
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
Applicant Signature Date
___________________________ ___________________________________________
Notary Public
Signature ________________________ Date_____________________
Printed Name _____________________ License # ___________ Commission Expiration Date _____________
600-00228 – Application to Waive Filing Fees & Service Costs (08/2020) Page 3 of 3
Determination of Financial Eligibility
☐ The Application is DENIED
The gross income of the applicant is greater than 150% of the poverty line, AND the applicant does not
receive public assistance. 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
☐ Applicant receives public assistance OR
☐ The gross income of the applicant is at or below 150% of the poverty income guidelines. OR
☐ Applicant is unable to pay the entire filing fee or 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 IS WAIVED.
☐ The Application is GRANTED in part and DENIED in part
Applicant is a financially needy person; however, based on the financial statement, Applicant is able to pay
the costs of service without expending household 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.
Date Signature of Clerk or Designee
___________________________ ___________________________________________
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 with 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 7 February 2021

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