Fillable Form 100 00508 0 (Vermont Judiciary)

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Form 100 00508 0 (Vermont Judiciary)

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100-00508 – Employer Disclosure (03/2019) Page 1 of 1
STATE OF VERMONT
SUPERIOR COURT
CIVIL DIVISION
Unit
Docket No.: __________________________
Plaintiff(s)
vs.
Defendant(s)
EMPLOYER DISCLOSURE
NOTE: IF YOU SEND THIS FORM TO THE COURT BEFORE THE HEARING DATE,
YOU DO NOT NEED TO COME TO THE HEARING.
1. Name of Company: _____________________________________________________________________
2. Do you pay the Defendant any wages, salary, commissions, Yes No
bonuses or other payments for work he/she does for you/your company?.................. ☐ ☐
3. Do you pay the Defendant any pension or retirement benefits?................................... ☐ ☐
4. Will the Defendant be receiving payments from you in the future,
even if he/she is not currently getting such payments?................................................. ☐ ☐
If so, when will he/she start receiving such payments? Date: __________________
5. How much does the Defendant take home in payments from you/your company? (Choose One)
$__________ per week $__________ every other week $__________ per month
$__________ Other. Please explain: ________________________________________________________
6. If the payments vary, please state an average monthly amount and explain why they vary.
$_____________ average per month Explanation: _____________________________________________
7. If you believe payments will change in the future, please explain:
_______________________________________________________________________________________
_______________________________________________________________________________________
Yes No
8. Are there any voluntary deductions from the employee’s paycheck? ………………………..☐ ☐
If so, please list type and amount per pay period:
_______________________________________________________________________________________
_______________________________________________________________________________________
I state under oath that the statements above are true.
Dated
_____________________________ _______________________________________
Signature
Signed and sworn to before me:
Date Signature of Notary Public Expiration Date
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Completed 19 July 2020

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