HELPING CHILDREN COPE WITH DIVORCE PROGRAM
APPLICATION FOR REDUCED FEE
THIS INFORMATION IS USED TO DETERMINE QUALIFICATION FOR REDUCED FEE ONLY AND IS NOT KEPT CONFIDENTIAL.
APPLICANT’S NAME
Address
Home Phone Type of Work
DO ANY OTHER ADULTS LIVE WITH YOU IN YOUR HOME? No Yes
Does this person contribute funds to pay towards the household expenses? No Yes
If YES, please complete the following information:
$ Amount per month this person contributes to pay household expenses.
Business income less expenses
Child support, spousal support,
alimony received
Welfare or public
assistance aid
*including any lottery winnings, gifts of cash, disability insurance, Social Security,
retirement income, dividend income
Do you have any savings accounts, certificates of deposit, money market accounts, stocks or bonds?
(These funds may be taken into account in determining your eligibility for subsidy.) No Yes
If YES, please state current value of (non- retirement) accounts and/or investments: $
By signing this application,
UNDER PENALTY OF PERJURY,
I affirm that this is a true representation of my income, assets,
and financial status as of this date, I understand this information may be made available upon request to the State of
Vermont.
__________________________________ ______________
Signature of Applicant Date
The above individual personally appeared before me
and made oath to the truth of the above matters.
__________________________________ ______________
Signature of Notary Date
Applicant qualifies for fee of $30.00 Applicant qualifies for fee of $15.00
Applicant does not qualify for reduced fee, $75.00 fee required
Fees must be paid before you will be considered registered for the course
and prior to attendance.
__________________________________ ______________________
Court Clerk/Clerk Designee Date
