Fillable Financial Disclosure Affidavit (Vermont Judiciary)

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Financial Disclosure Affidavit (Vermont Judiciary)

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Financial Disclosure Affidavit
100-00127 – Financial Disclosure Affidavit (04/2015) Page 1 of 2
State of Vermont
Vermont Superior Court
Division
Unit
Type of Case
Docket Number
Name:
Others Living with You (include adults and children)
Street:
City, State, Zip:
Telephone Number (Day)
( )
Telephone Number
(Alternate)
Date of Birth
Mo Day Year
/ /
Total Number in Household (including yourself)
EMPLOYMENT
Are you employed? Y N
Circle Y for yes or N for no
Employer(s) Name(s) and Address(es) :
If yes, fill in Name and Address of each
employer
INCOME
EXPENSES
Yes
No
Enter your household’s monthly expenses
Do you receive Public Assistance?
(including TANF/Reach UP; SSI, General Assistance)
Y
N
Rent or Mortgage Pmt.
$________________
Do any family members living with you receive
public assistance
Y
N
Electric Service
$________________
Monthly Income
during the previous year
Food
$________________
You
Other Household
Members Living With
You
Fuel (heat and/or gas)
$________________
Gross Income from Wages
$_____________
$_____________
Phone
$________________
Self Employment/Business
Income (other than wages)
$_____________
$_____________
Clothing
$________________
Investment or Income from
assets not included above
$_____________
$_____________
Medical
$________________
Unemployment
Compensation
$_____________
$_____________
Child Support
$________________
Child Support
$_____________
$_____________
Auto Loan Payments
$________________
Public Assistance
$_____________
$_____________
Property Taxes
$________________
Other Income (Including Disability
Insurance and Social Security)
$_____________
$_____________
Insurance(Incl. Health, Auto, etc)
$________________
Total Income
$
$
Other Expenses:
please specify
$________________
Total Monthly Income
(Your income plus Household Members )
$
$________________
Is your income in the last 30 days
significantly different from the previous year
Y
N
$________________
If YES, please explain the circumstances on page 2.
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
$_____________
$_______________
Financial Disclosure Affidavit
100-00127 – Financial Disclosure Affidavit (04/2015) Page 2 of 2
I have additional assets
Y
N
If YES, please describe below
Additional Assets:
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
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 any 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.
Signed and sworn before me:
Defendant’s Signature
Date
Notary Public
Date
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 your current monthly income and the reasons why it changed.
My current monthly income is:
$
My current household income is:
$
The reason for the change is: (This section must be filled out if you have a change in income.)
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Financial Disclosure Affidavit (Vermont Judiciary)

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Completed 30 July 2020

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