Form 228 - Application To Waive Filing Fees And Service Costs
Download a blank fillable Form 228 - Application To Waive Filing Fees And Service Costs in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 228 - Application To Waive Filing Fees And Service Costs with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2APPLICATION TO WAIVE FILING FEES AND SERVICE COSTS
Division
Unit
Docket Number
State of Vermont
Vermont Superior Court
First
Last
Others Living with You (include adults and children)
Name
Street Address
Town/City
State
Zip
Telephone Number
Date of Birth
Social Security Number
Total Number in Household
(including Yourself)
EMPLOYMENT
Employer(s) Name(s) and Address(es) :
Are you employed?
Yes No
If Yes, fill in employer’s name(s) and
address(es)
INCOME
EXPENSES
Yes
No
If all adults living with you receive public
assistance, it is not necessary to fill out the
Do you receive Public Assistance?
(
Expenses section below.
including TANF/Reach UP; SSI, General Assistance)
Do Any Family Members Living With You
Otherwise, enter your monthly household expenses
Receive Public Assistance
Rent or Mortgage Pmt.
Current Monthly Income
$________________
Other Household
You
Members Living
Electric Service
With You
$________________
Gross Income from Wages
Phone
$____________
$_____________
$________________
Self Employment/Business Income
Fuel (heat and/or gas)
(other than wages)
$____________
$_____________
$________________
Food
Unemployment Compensation
$____________
$_____________
$________________
Child Support
Clothing
$____________
$_____________
$________________
Public Assistance
Medical
$____________
$_____________
$________________
Other Income
(Including Disability
Child Support
$____________
$_____________
$________________
Insurance and Social Security)
$
$
Total Income
Auto Loan Payments
$________________
Total Monthly Income
$
Property Taxes
(Your income plus Household members)
$________________
Total Income in the past 12
$
Insurance(Incl. Health, Auto, etc)
$________________
months
Is your income in the last 30 days significantly different
Yes
No
Other Expenses
$________________
from your monthly income during the previous year
If YES, please explain the circumstances on the next page.
$
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
Additional Assets:
If Yes, describe them below
I have additional assets: Yes
No
Vehicles
Make, Model, Year
Fair Market
Amount Owed
Net value
Value (FMV)
$
$
$
$
$
$
$
$
$
$
$
$
Real Property
Description
FMV
Mortgage
Net Value
$
$
$
$
$
$
Other Assets
Description
FMV
Use additional sheets as
e.g. tools,
necessary.
$
equipment, recreational
vehicles, electronics, stocks,
$
bonds, etc.
$
Form 228 - IFP (11/2014)
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal