Vermont Form 813 – Fill Out and Use This PDF

FORM 813 A - FINANCIAL AFFIDAVIT

INSTRUCTIONS: You are required to complete and file the 813A if-

1.You are a party in a newly filed divorce, civil union dissolution, legal separation, annulment or parentage action and you and the other party have minor children; OR

2.You or the other party are seeking to modify a previously issued order regarding child support or spousal maintenance (alimony); OR

3.You are the person required to pay support, and an enforcement action has been filed against you; OR

4.Your child is in the custody of the Department of Children and Families and support has been requested of you; OR

5.You are ordered by the Court to complete and file this form or the other party requests that you fill out the form as part of the discovery process.

DEADLINE FOR FILING: This form must be filed with the court before or at your first case manager's conference. If no conference is scheduled it must be filed at least five days before your first scheduled court hearing.

YOU MUST SEND A COPY OF YOUR COMPLETED FORM TO THE OTHER PARTY AT THE SAME TIME THAT YOU FILE IT WITH THE COURT.

When you have completed the form and filled in all the required information, you must sign the Affirmation section below and have your signature notarized.

AFFIRMATION

I have read and filled in all the information requested.

I hereby affirm of my own knowledge that the facts and financial information I have stated are true and correct as of the date of this Affirmation and that I am not omitting any source or amount of income or other information requested on this form. I understand that any false information may constitute perjury by me. I also understand that if I fail to provide the required information or give misinformation, the judge may order sanctions against me.

SECTION I - INCOME

I am self-employed (sole proprietor, partnership, d/b/a) as a

I am not currently employed because

A.MONTHLY GROSS INCOME FROM EMPLOYMENT - Income before any deductions for payroll taxes or benefits. (If your income varies throughout the year, calculate your annual income and divide by twelve to get your monthly income in each category below.)

To calculate MONTHLY amounts from paychecks:

If you are paid weekly, multiply average weekly pay by 4.333.

If you are paid every other week, multiply average bi-weekly pay by 2.165

If you are paid twice a month, multiply average semi-monthly pay by 2

ATTACH 4 MOST RECENT PAY CHECK STUBS.

2.TIPS, COMMISSIONS, BONUSES, ROYALTIES

3.SELF EMPLOYMENT INCOME

(Complete Self Employment Attachment on page 11 or attach IRS SCHEDULE C from tax filing)

4. PERSONAL EXPENSES PAID BY EMPLOYER

(for example: cell phone, car, housing allowance, meals, military allowances)

Total Income from Employment

B. OTHER SOURCES OF INCOME (Indicate Monthly Amount)

1. RENTAL INCOME

(Complete Rental Income Attachment on page 10 or attach IRS SCHEDULE E from tax filing)

2.RETIREMENT/PENSIONS

3.UNEMPLOYMENT INSURANCE BENEFITS

4.WORKER'S COMPENSATION and/or DISABILITY INSURANCE

SECTION II - PUBLIC BENEFITS

SECTION III - INCOME/EXPENSES of MINOR CHILDREN

''Minor Children '' means children under 18 or children over the age of 18 but still in high school.

A.LIST ALL MINOR CHILDREN YOU HAVE WITH THE OTHER PARTY

B.LIST ALL OTHER MINOR CHILDREN FOR WHOM YOU PROVIDE SUPPORT

C.LIST ALL CHILDREN FOR WHOM YOU ARE ORDERED TO PAY CHILD SUPPORT

D.HEALTH INSURANCE AVAILABLE THROUGH YOUR EMPLOYMENT:

You must complete this paragraph if you could get this kind of insurance through your job even if your children are not enrolled. Check with your Payroll or Human Resources Department to obtain amount of your monthly payroll contribution to the cost.

TOTAL MONTHLY FAMILY HEALTH INSURANCE COST TO EMPLOYEE TOTAL MONTHLY TWO PERSON COST TO EMPLOYEE

TOTAL MONTHLY COST FOR SINGLE PERSON COVERAGE TO EMPLOYEE

E.YOUR CHILD CARE COSTS FOR CHILDREN OF THIS RELATIONSHIP

(If monthly amounts change during the year, use total annual amount divided by 12) TOTAL MONTHLY CHILD CARE COSTS (before subsidy)

TOTAL MONTHLY CHILD CARE SUBSIDY OUT OF POCKET COSTS (Total costs minus subsidy)

Transfer out of pocket costs to Page 9, line 51.

F.YOUR EXTRAORDINARY EXPENSES FOR CHILDREN OF THIS RELATIONSHIP

Child's Uninsured Medical expenses

Child's Educational Expenses

Child's Special Needs Expenses

G. MONTHLY INCOME RECEIVED BY A CHILD OF THIS RELATIONSHIP

1.DISABILITY BENEFITS

2.SOCIAL SECURITY BENEFITS

3.OTHER

Name of Parent who receives the child's benefit:

SECTION IV - LOANS AND DEBTS

I. LOANS

A. Primary Residence Loans:

D. Other Loans

B. Other Debts (for example tax liens, hospital bills, collection accounts)

SECTION V - EXPENSES

I. MONTHLY EXPENSES: List your monthly expenses. For those expenses paid other than monthly, take the annual amount and divide it by 12. If amount paid changes from month to month, use the annual amount divided by 12.

47.STATE OF VERMONT

48.OTHER TAXES WITHHELD/PAID III. CHILDREN'S EXPENSES

MONTHLY EXPENSES FOR CHILDREN OF THIS RELATIONSHIP PAID BY YOU

49.Clothing and Shoes

50.Diapers

51.Out-of-Pocket Child Care Costs related to your employment

52.School lunches

53.School supplies

54.Fees/expenses for special activities (e.g., piano lessons, sports)

55.Summer Camp

56.Private School Tuition

57.Uninsured Medical/Dental Expenses

58.Child Support you pay for your children of this relationship

59.Miscellaneous: Please itemize below.

Miscellaneous 1

Miscellaneous 2

Miscellaneous 3

Miscellaneous 4

TOTAL MONTHLY EXPENSES FOR CHILDREN

RENTAL INCOME ATTACHMENT (Schedule E)

Enter this amount on Page 2 A Line 3 (Section I) of Form 813A

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