Free Application to Proceed In Forma Pauperis - Vermont

Form 228

APPLICATION TO PROCEED IN FORMA PAUPERIS
Court Unit No. Circuit/County Date of Birth Type of Case Social Security Number Docket Number Telephone Number (Day)

State of Vermont
Name of Applicant

Street Address

City, State, Zip Code

Telephone Number (Evening)

Names(s) of Dependents (People you Support)

Relationship

Total Number of Dependents (including applicant)

IMPORTANT
Do you receive public assistance*? Do you cohabit *** with anyone?

Yes

No

Relationship of Applicant to Cohabitant?

Income Previous 30 Days Previous 12 Months
Applicant Gross Income from Wages Business Income less Expenses Unemployment Comp. Child Support Public Assistance* Other Income** Cohabitant *** Applicant

Assets
Real Estate Owned: Location Fair Market Value Outstanding Mortgage(s) = Net Worth

Monthly Expenses
Phone

$

-

Cohabitant ***

$

$

$

Rent Utilities/Fuel Food $ $ $ Motor Vehicles, Motorcycles, All Terrain Vehicles, Boats Clothing
Year Make/Model Amount owed Net Worth Medical

$

$

$ Cash on Hand
$ $ $A
(A+B)

$ $

Total

$B

$ Checking Account(s): Name of Bank and Account #

TOTAL ANNUAL INCOME

$

*Public Assistance could include: TANF/Reach Up, SSI and General Assistance ** "Other" could include Disability Insurance and Social Security *** "Cohabitant": adult family members living with applicant
Applicant's Employer: Name & Address Cohabitant's Name Cohabitant's Employer: Name & Address

Savings Account: Name of Bank and Account # $

$

Other Other

$ $

TOTAL ASSETS

$

Child Support Insurance: Home Health Auto Life Loan Payments: Motor Vehicles Home Mortgage Property Taxes Other Expenses Other Other $

TOTAL

EXPENSES

I request the Court waive filing fees and/or pay service fees in the above entitled matter because of my low income. I make the above answers UNDER PENALTY OF PERJURY. If at any time during the pendency of this action I become financially able to pay for the filing fees and/or service fees, I will do so.
The above individual personally appeared before me and made oath to the truth of the above matters.
Notary Public Date Signature of Applicant Date

FINDINGS AND ORDER 1. The Applicant is Not a Financially Needy Person in that the applicant does have sufficient liquid assets, sufficient non-liquid assets which would provide collateral to borrow money, or sufficient income in excess of basic expenses to pay filing fees and service fees. Applicant's Request to Proceed In Forma Pauperis is hereby DENIED. You must pay $ to the court clerk within 30 days or the case will be dismissed. 2. The Applicant is a Financially Needy Person in that the applicant does not have sufficient liquid assets, sufficient non-liquid assets which would provide collateral to borrow money, or sufficient income in excess of basic expenses to pay filing fees or the service fees. Applicant's Request to Proceed in Forma Pauperis is hereby GRANTED. The ability to pay will be reassessed at the end of the case. 3. The Applicant is a Financially Needy Person. However, based on the financial statement, the applicant can pay the costs of service. The applicant is ordered to pay $ in service fees to the court clerk. to the sheriff. Respondent may be required to pay the remainder of service and filing fees and any additional service fees incurred during the pendency of this case.
Court Clerk/Clerk Designee Date

Notice to Applicant: You are advised that you have the right to appeal this order to the judge of this court. Your appeal must be filed in writing with the clerk of this court within 7 days of the date of this order.
SML Rev. 11/06

Distribution:

Court

Applicant

Service of Process Officer

Respondent