Vt. R. App. P. Form 4
(Caption appropriate to the court in which the motion is filed)
I, __________________ being first duly sworn, depose and say that I am the __________________, in the above-entitled case; that in support of my motion to proceed on appeal without being required to prepay fees, costs or give security therefor, I state that because of my poverty I am unable to pay the costs of said proceeding or to give security therefor; that I believe I am entitled to redress; and that the issues which I desire to present on appeal are the following:
I further swear that the responses which I have made to the questions and instructions below relating to my ability to pay the cost of prosecuting the appeal are true.
1. Are you presently employed?
a. If the answer is yes, state the amount of your salary or wages per month and give the name and address of your employer.
b. If the answer is no, state the date of your last employment and the amount of the salary and wages per month which you received.
2. Have you received within the past twelve months any income from a business, profession or other form of self-employment, or in the form of rent payments, interest, dividends, or other source?
a. If the answer is yes, describe each source of income, and state the amount received from each during the past twelve months.
3. Do you own any cash or checking or savings account?
a. If the answer is yes, state the total value of the items owned.
4. Do you own any real estate, stocks, bonds, notes automobiles, or other valuable property (excluding ordinary household furnishings and clothing)?
a. If the answer is yes, describe the property and state its approximate value.
5. List the persons who are dependent upon you for support and state your relationship to those persons.
I understand that a false statement or answer to any questions in this affidavit will subject me to penalties for perjury.
______________________________________________________________________
SUBSCRIBED AND SWORN TO before me this ________ day of __________________, 19____.
Let the applicant proceed without pre-payment of costs or fees or the necessity of giving security therefor.
______________________________________________________________________
(Superior) (District) Judge
Vt. R. App. P. Form 4