Plumbers License Application - Vermont Department Of Public Safety Page 4
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5SECTION 9: Compliance Questions
Applicant's Statement Regarding:
Child Support, Taxes, Unemployment Compensation, Fines & Penalties
Child Support [15 V.S.A. § 795] - You must check one of the statements below regarding child support:
I do not have any children, OR
I do not owe any child support, OR
I do owe child support, but am under a plan with the Office of Child Support to pay all child support
due
This certification is in regards to any children residing in Vermont, and where the license/certificate holder is a resident of
Vermont, to any children residing in any other state or territory of the United States. For assistance contact the Office of Child
Support, 103 South Main Street, Waterbury, VT 05676 [(802) 241-2180]
Taxes [32 V.S.A. § 3113] - You must check one of the statements below regarding taxes.
All tax returns have been filed. I do not owe any taxes, OR
I owe taxes but am under a plan with the Department of Taxes to pay all taxes due, or the tax payments are
under appeal
To determine status of a payment plan or appeal, or for assistance, contact the supervisor of tax collections [(802)
828-6809]
Unemployment Compensation [21 V.S.A. § 1378] - You must check one of the statements below regarding
unemployment contributions or payments in lieu of unemployment contributions.
I am not now, nor have I ever been, an employer; OR
I do not owe any unemployment compensation, OR
I owe unemployment compensation but am under a plan with the Unemployment Division to pay any and all
unemployment compensation due
To determine status of a payment plan, or for assistance, contact the department of labor
[(802) 828-4254]
Fine or Penalty [4 V.S.A. § 1110] – You must check one of the statements below regarding a fine or penalty
issued by the judicial bureau or district court.
I am not under any obligation to pay a fine or penalty due to any unpaid judgment issued by the judicial bureau
or district court, OR
I am under such an obligation and am in good standing with respect to the obligation because 60 days or fewer
have elapsed since the date a judgment was issues, or due to a repayment plan approved by the judiciary
For assistance contact the Office of Court Administrator, 109 State Street, Montpelier, VT 05609-0701
[(802) 828-3278]
Statement of Applicant
I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and
accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the
denial of my application for licensure/certification or renewal. (The maximum penalty for perjury is 15 years in
prison and/or a $10,000 fine. 13 VSA § 2901)
Signature of Applicant: ___________________________________________________ Date: ____________________
Created on 9/7/2012
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