Fillable FINANCIAL AFFIDAVIT - NON-DIVORCE (Vermont Judiciary)

Fill Online, Printable, Fillable, Blank FINANCIAL AFFIDAVIT - NON-DIVORCE (Vermont Judiciary) Form

Use Fill to complete blank online VERMONT JUDICIARY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

FINANCIAL AFFIDAVIT - NON-DIVORCE (Vermont Judiciary)

On average this form takes 16 minutes to complete

The FINANCIAL AFFIDAVIT - NON-DIVORCE (Vermont Judiciary) form is 2 pages long and contains:

  • 0 signatures
  • 16 check-boxes
  • 57 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Vermont Judiciary forms online.

BROWSE VERMONT JUDICIARY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
400-00813S – Financial Affidavit (Non-Divorce) (09/2016) Page 1 of 2
STATE OF VERMONT
SUPERIOR COURT
FAMILY DIVISION
Unit
Docket No.
Plaintiff
Defendant
Name
DOB
v.
DOB
FINANCIAL AFFIDAVIT - NON-DIVORCE
INSTRUCTIONS: You are required to complete and file this financial affidavit as part of your court case. You must
complete the form and file it with the Court at or before your first case management conference. You must also send or
bring a copy of the form for the other party(s) as well, along with the other supporting financial documents listed on the
conference notice. You may attach additional sheets as needed to provide complete information.
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
$
0.00
400-00813S – Financial Affidavit (Non-Divorce) (09/2016) Page 2 of 2
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
____________________________ _______________ ____________________________________
____________________________ _______________ ____________________________________
____________________________ _______________ ____________________________________
____________________________ _______________ ____________________________________
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):_____________________________
___________________________________________________________________________________________
AFFIRMATION
I have read and filled in all of 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 and 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.
____________________________
Signature of person making affidavit
__________________________________________________________________________________________________
Date Notary Public Commission Expires
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

FINANCIAL AFFIDAVIT - NON-DIVORCE (Vermont Judiciary)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document