Form 100-00127 - Financial Disclosure Affidavit
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1
2Financial Disclosure Affidavit
Division
Unit
Type of Case
Docket Number
State of Vermont
Vermont Superior Court
Name:
Others Living with You (
include adults and children)
Street:
Address:
City, State, Zip:
(
)
Telephone Number
(Day)
Telephone Number
(Alternate)
Mo
Day
Year
/
/
Date of Birth
Total Number in Household
(including yourself)
EMPLOYMENT
Employer(s) Name(s) and Address(es) :
Are you employed? Y N
Circle Y for yes or N for no
If yes, fill in Name and Address of each
employer
INCOME
EXPENSES
Enter your household’s monthly expenses
Yes
No
Do you receive Public Assistance?
Y
N
Rent or Mortgage Pmt.
$________________
(
including TANF/Reach UP; SSI, General Assistance)
Do any family members living with you receive
Electric Service
$________________
Y
N
public assistance
Monthly Income
Food
$________________
during the previous year
Other Household
You
Members Living With
Fuel (heat and/or gas)
$________________
You
Gross Income from Wages
$_____________
$_____________
Phone
$________________
Self Employment/Business
$_____________
$_____________
Clothing
$________________
Income (other than wages)
Investment or Income from
$_____________
$_____________
Medical
$________________
assets not included above
Unemployment
$_____________
$_____________
Child Support
$________________
Compensation
Child Support
$_____________
$_____________
Auto Loan Payments
$________________
Public Assistance
$_____________
$_____________
Property Taxes
$________________
Other Income
(Including Disability
$_____________
$_____________
Insurance(Incl. Health, Auto, etc)
$________________
Insurance and Social Security)
Other Expenses:
$
$
Total Income
$________________
please specify
Total Monthly Income
$
$________________
(Your income plus Household Members )
Is your income in the last 30 days
Y
N
$________________
significantly different from the previous year
$
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
$__________
_________________
______________________
_____
Fair Market
Checking Account
$__________
$_____________
$_______________
Value
Outstanding
Savings Account
$__________
$_____________
$_______________
Mortgage
Total Cash Assets
$_____________
$_______________
$__________
Net Value
100-00127 – Financial Disclosure Affidavit (04/2015)
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Parent category: Legal