Fillable DISCLOSURE OF EXEMPT INCOME (see List of Exemptions (Vermont Judiciary)

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DISCLOSURE OF EXEMPT INCOME (see List of Exemptions (Vermont Judiciary)

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100-00128 – Disclosure of Exempt Income (04/2015) Page 1 of 1
STATE OF VERMONT
SUPERIOR COURT
CIVIL DIVISION
Unit
Docket No.: __________________________
Plaintiff(s)
vs.
Defendant(s)
DISCLOSURE OF EXEMPT INCOME
(see List of Exemptions at www.vermontjudiciary.org)
I certify that the following statement is a true and accurate description of my income
☐ I am currently eligible, or was eligible within the last two months, for benefits from:
☐ The Vermont Department for Children and Families (DCF)
☐ The Department of Vermont Health Access (DVHA)
☐ My income source(s) include one or more of the following exempt sources:
☐ Social Security Income
☐ Social Security or Social Security Disability
☐ Veteran’s Benefits
☐ Unemployment Compensation
☐ Workers’ Compensation
☐ My reasonable living expenses for myself and my family members living with me are more
than my income after taxes. I have completed and attached Financial Disclosure Affidavit
showing my income and expenses.
☐ My income is otherwise exempt because:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I hereby swear or affirm that the above certification is true and
accurate
Signature:
Name (print or type):
Address
Date
.
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DISCLOSURE OF EXEMPT INCOME (see List of Exemptions (Vermont Judiciary)

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Completed 30 July 2020

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