Vt. Stat. tit. 12 § 6010
The certificate to be delivered by the commissioners to the prisoner admitted to the poor debtor's oath shall be substantially as follows:
STATE OF VERMONT, |
To all whom it may concern, |
......................... County, ss. } |
Greeting:
............................, a prisoner confined in the ......................... jail in ......................... in the county of ........................................, on an execution in favor of ................................... of .................... in the county of ......................... and State of ........................., dated the ............... day of ..................................., 20 ......, for .............................. dollars and .................... cents damages (or debt) and ................................... dollars and .............................. cents cost, signed by ........................., has this day been admitted to the poor debtor's oath, and ought to be discharged. The creditor was (or was not) notified, and did (or did not) attend.
Given under our hands at ........................., this .................... day
of ........................., 20 ........
} Commissioners.
12 V.S.A. § 6010