Page 1 of 4 INSTRUCTIONS FOR APPLICATION FOR DEFERRAL OR WAIVER OF FEES & DECLARATION IN SUPPORT Filing fees are NOT required in appeals in criminal, habeas corpus, post-conviction relief, juvenile court, involuntary commitment of persons alleged to have a mental illness or an intellectual disability, Psychiatric Security Review Board, and State Board of Parole cases. Filing fees are required for all other appeals and agency reviews. A list of fees is available at http://www.courts.oregon.gov/Pages/fees.aspx , more specifically at: http://www.courts.oregon.gov/courts/appellate/rules/Pages/cases.aspx . The court accepts cash, credit cards (Visa and MasterCard only), and money orders or checks made out to State Court Administrator. If you cannot afford to pay the amount required, you may ask the court to defer or waive those fees. If the court defers appellate court fees then you do not need to pay immediately. But, you still have to pay all deferred fees according to the order deferring fees issued by the Court of Appeals. If you want to apply for a waiver or deferral of fees, complete the following form: APPLICATION FOR DEFERRAL OR WAIVER OF FEES & DECLARATION IN SUPPORT You must completely fill out the application, including the declaration. Do not leave any sections blank. If a section does not apply to you, write in 223N/A224. Fill in the case heading. Date, sign, and print your name. The application does not need to be served on anyone. Only the original need be filed with the appellate court. Generally, the court will keep the document confidential (only court staff and the judge will see it), but, at the request of another party to the case and for good cause shown, the court will provide a copy to the adverse party. At your request only, at the end of your case, the court may address fee deferrals if any amount is still unpaid. At your request the court will review the situation and decide whether any remaining unpaid fees should be waived. If you make such a request, inform the court if your financial and asset information has changed substantially. Inmates: If an inmate seeks to file an action against a public body then an inmate222s application for deferral or waiver of fees & declaration in support must be accompanied by an inmate trust account statement which covers the last six months. ORS 30.643. The statement must be certified as correct by an official or an employee of the Department of Corrections charged with the responsibility of overseeing inmate trust accounts. Without this statement, the court cannot act on an inmate222s application. American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 4 IN THE COURT OF APPEALS OF THE STATE OF OREGON Appellant (or Petitioner) v. Respondent(s) APPLICATION FOR DEFERRAL OR WAIVER OF FEES & DECLARATION IN SUPPORT Applicant222s Full Name: First Middle Last Appellate Case No. (if known) Lower Court or Agency No. Lower Court or Agency Name ACCESS TO THIS DOCUMENT IS RESTRICTED TO PROTECT THE PRIVACY OF PARTIES I am the appellant respondent other: . I am unable to pay all or part of the fees right now. 1. I am applying for deferral or waiver of the following fees: Filing Fees Motion/Response to Motion Fee 2. If fees are not waived, I understand that payment is a debt to the state of Oregon. Additional fees may be added for administrative and collection costs. 3. I understand that if the Administrator or the Appellate Commissioner denies my application, I have the right to ask a judge to review my application. 4. Any waiver or deferral I am granted during the case may be revoked in full or in part at the end of the case based on the final outcome. DECLARATION 1. PERSONAL Date of Birth (month/day/ year) *SSN: Driver License/State ID: *I am providing my Social Security number voluntarily. I understand that I cannot be forced to provide it or be denied consideration solely for failure to provide it. It may be used to verify my identification, employment information, and for collection of fees. Number of people living in your household: American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 4 2. PUBLIC ASSISTANCE / LEGAL AID Are you represented in this case by a legal aid attorney? Yes (Name): No If you indicated 223no224, check any programs you currently receive assistance from: (include the amount you receive PER MONTH) Food Stamps (SNAP-Supplemental Nutrition Assistance Program) - $ Supplemental Security Income (SSI) - $ Temporary Assistance to Needy Families (TANF) - $ Oregon Health Plan (OHP) Total monthly benefits received: $ Complete sections 3-6 with amounts for all members of your household combined 3. EMPLOYMENT AND INCOME Total monthly income from all jobs, before taxes are taken out: $ Total monthly income from other sources: $ (including annuities, settlement income, and any other source of funds or support) TOTAL INCOME FROM ALL SOURCES: $ 4. ASSETS Total cash available from all accounts: $ (cash, checking account, savings, etc.) List any assets you have including vehicles, real estate, boats, guns, jewelry, livestock, business interests, etc.: Value of assets: TOTAL VALUE OF ALL ASSETS & CASH: $ 5. LIVING EXPENSES (per month): Home: $ (rent, mortgage, utilities, cell phone, food) Transportation: $ (parking, gas, bus, insurance, vehicle loan payments) Other: $ (student loans, day care, court fines, medical, child support, credit cards, etc.) TOTAL MONTHLY LIVING EXPENSES: $ American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 4 6. OTHER INFORMATION YOU WANT COURT TO CONSIDER I hereby declare that the above statements are true to the best of my knowledge and belief. I understand they are made for use as evidence in court and I am subject to penalty for perjury. Date Signature Name (printed) Contact Address City, State, Zip Contact Phone American LegalNet, Inc. www.FormsWorkFlow.com