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Form 228 APPLICATION TO PROCEED IN FORMA PAUPERIS Unit No. Docket Number Circuit/County Type of Case Court State of Vermont Street Address City, State, Zip Code Telephone Number (Evening) Total Number IMPORTANT of Dependents Do you receive public assistance*? (includingapplicant) Income Assets Monthly Expenses Phone $ $ Home Cash on Hand Health $ Auto Checking Account(s): Name of Bank and Account # $ Life $ TOTAL ANNUAL INCOME $ Savings Account: Name of Bank and Account # $ Other $ Other $ Other TOTAL TOTAL ASSETS $ 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. Signature of Applicant Date Notary Public Date The above individual personally appeared before me and made oath to the truth of the above matters. 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 The ability to pay will be reassessed at the end of the case. GRANTED. 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. Date Court Clerk/Clerk Designee 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 Amount owed Property Taxes Distribution: Court Applicant Service of Process Officer Respondent Rent $ Date of Birth Social Security Number Utilities/Fuel 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. Previous 30 Days Previous 12 Months Applicant - Business Income less Expenses Unemployment Comp. Child Support Public Assistance* Other Income**$ $ $ $ $ $ $ $ Cohabitant *** Applicant AB Cohabitant *** Total Gross Income from Wages *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 Cohabitant's Employer: Name & Address Applicant's Employer: Name & Address Cohabitant's Name Do you cohabit *** with anyone?Relationship of Applicant to Cohabitant? (A+B) Name of Applicant Telephone Number (Day) Names(s) of Dependents (People you Support) Relationship Yes No Real Estate Owned: Location Fair Market Value - Outstanding Mortgage(s) = Net Worth $ $ $Motor Vehicles, Motorcycles, All Terrain Vehicles, Boats Net Worth Year Make/Model $ $ FoodClothing MedicalChild SupportInsurance: Loan Payments:Motor Vehicles Home Mortgage Other ExpensesOther