IN THE COURT OF APPEALS OF THE STATE OF OREGON ______________________________________, v. ______________________________________. ) ) ) ) ) ) ) Case No. _________________ Appellant/Petitioner Respondent APPLICATION FOR WAIVER OR DEFERRAL OF FEES I am asking for waiver or deferral of fees in this case because I am unable to pay all or part of the fees. The following information is complete and accurate to the best of my knowledge. I understand that I am required to provide documentation verifying this information. I understand that failure to do so could result in my request being denied. 1. I am applying for WAIVER ( A fee “waiver” means that you are not required to pay some or all of your fees because the court has determined that, based on your income and other relevant factors, you are unable to pay.) OR DEFERRAL (A fee “deferral” means that the court has determined that you must pay the court fees, but that you can pay the fees owed over a specified period of time.) of the following fees (check all that apply): Appellant's Filing Fee(s) Respondent's Appearance Fee(s) Motion Fee(s) - Filing Motion Fee(s) – Response 2. I declare that (check one of the boxes below): I am receiving assistance from at least one of the following programs: Food Stamps Oregon Health Plan Standard Oregon Health Plan Plus Oregon Health Plan with Limited Drug Supplemental Security Income (SSI) Temporary Assistance to Needy Families (TANF) If you checked the above box, you must show proof that you are receiving assistance from the program. You do NOT need to fill out a Declaration for Waiver or Deferral of Fees unless you are enrolled in the Oregon Health Plan’s Qualified Medicare Beneficiary (QMB) program or Citizen Alien-Waived Emergency Assistance (CAWEM) program. If you are enrolled in QMB or CAWEM, you must complete and file the declaration with this application. Even though I am NOT receiving assistance from any of the above programs, I am still unable to pay the fees. If you checked the above box, you must complete and file a Declaration for Waiver or Deferral of Fees with this application. The declaration is designed to prove to the court that you do not have sufficient financial resources to pay the fees. If the court defers fees, I understand that: Application for Waiver or Deferral of Fees Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com a. The fees are an obligation owed by me to the State of Oregon and that the court may place me on a payment schedule. I agree to pay the fees according to the payment schedule. If I fail to pay according to the payment schedule, the total amount of the unpaid fees are due immediately. b. The court may enter a judgment against me for the unpaid amount of the fees that are deferred and the judgment will be enforced without regard to the outcome of the case. See ORS 21.605. c. If the court establishes a payment schedule or refers a judgment for collection, the law allows administrative and collection costs to be automatically added to the judgment without further notice to me or further action by the court. 3. I understand that if the clerk denies my application, I have the right to ask a judge to review my application. __________ __________________________________________ Date Signature of Applicant __________________________________________ Name of Applicant (printed or typed) CERTIFICATE OF SERVICE I certify that I served a true copy of this application on: (NAME OF OPPOSING PARTY) (ADDRESS OF OPPOSING PARTY) (NAME OF OPPOSING PARTY) (ADDRESS OF OPPOSING PARTY) __________ __________________________________________ Date Signature of Applicant __________________________________________ Name of Applicant (printed or typed) Application for Waiver or Deferral of Fees Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com IN THE COURT OF APPEALS OF THE STATE OF OREGON ______________________________________, v. ______________________________________. ) ) ) ) ) ) ) Case No. _________________ Appellant/Petitioner Respondent DECLARATION FOR WAIVER OR DEFERRAL OF FEES (TO BE COMPLETED BY APPLICANT) ACCESS TO THIS DOCUMENT IS RESTRICTED PURSUANT TO THE COURT’S POLICY TO PROTECT THE PERSONAL PRIVACY INTERESTS OF PARTIES 1. PERSONAL Full Name of Applicant ___________________________________________________________________________ FIRST NAME MIDDLE NAME LAST NAME DATE OF BIRTH Residence Address ______________________________________________________________________________ STREET ADDRESS CITY STATE ZIP Mailing Address (if different) _______________________________________________________________________ ADDDRESS CITY STATE ZIP Telephone Number _____________ *SSN ______________ ODL/ID ____________ Marital Status ______________ *I am providing my Social Security number on a voluntary basis. I understand that I cannot be compelled to provide it or be denied consideration solely for failure to provide it. It may be used to verify my identification, credit and employment information, and for collection purposes of court imposed monetary obligations. Names, Relationships, and ages of legal dependants living in household: Name/Relationship Age Name/Relationship Age _____________________________ _____________________________ _____________________________ ______ ______ ______ ______ ______ ______ _____________________________ _____________________________ _____________________________ 2. EMPLOYMENT AND INCOME Currently Employed Not Currently Employed How long since last employment? ____________________ Employer Name (use previous employer if not currently employed) _________________________________________ Employer Address ________________________________________________ Work Phone ___________________ Occupation (job title) _______________ Length of Employment ____________ Amount of Last Paycheck $________ Hourly Wage $ _______ Hours Per Week _______ Monthly Income: Gross $_________ Net $________ (before taxes) (after taxes) Spouse’s Employment Currently Employed Not Currently Employed How long since last employment? ____________________ Employer Name (use previous employer if not currently employed) _________________________________________ Employer Address ________________________________________________ Work Phone ___________________ Occupation (job title) _______________ Length of Employment ____________ Amount of Last Paycheck $________ Hourly Wage $ _______ Hours Per Week _______ Monthly Income: Gross $_________ Net (after taxes) $________ Other income for you, spouse, dependants, or household members (for example: Social Security, unemployment, retirement, public assistance, child support, workers’ compensation, disability, tribal benefits, etc.): Source of Income (describe) Amount How long received? How often received? ______________________________________ $_________ ________________ _________________ ______________________________________ $_________ ________________ _________________ ______________________________________ $_________ ________________ _________________ Declaration for Waiver or Deferral of Fees Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Other household members who help pay your living expenses: Relationship Amount ______________________________________ $_________ ______________________________________ $_________ Payment for what (describe)? _____________________________________ _____________________________________ 3. MONEY ON HAND / IN BANK OWNED BY YOU AND YOUR SPOUSE Checking Account Number ___________________ Bank/Credit Union ___________________ Savings Account Number ____________________ Bank/Credit Union ___________________ Other Account Number ______________________ Institution __________________________ 4. MOTOR VEHICLES OWNED BY YOU AND YOUR SPOUSE Year, Make, and Model Value Amount Owing ________________________________ $__________ $__________ ________________________________ $__________ $__________ 5. REAL ESTATE OWNED BY YOU AND YOUR SPOUSE Year Purchase Address (include city and state) Purchased Price _____________________________ _______ $_______ _____________________________ _______ $_______ Value $_______ $_______ Cash $___________ Balance $ _________ Balance $ _________ Balance $ _________ Payments made to: ___________________________ ___________________________ Amount Owing $_______ $_______ Payments made to: ___________________ ___________________ 6. ALL OTHER PROPERTY OR ASSETS (example: stocks, bonds, trailers, ATVs, RVs, boats, guns, jewelry, livestock, etc.): Description Value Description Value _____________________________ _____________________________ _____________________________ $______ $______ $______ _____________________________ _____________________________ _____________________________ $______ $______ $______ 7. MONEY OWED TO YOU OR YOUR SPOUSE BY OTHERS (example: tax refunds, judgments, trust funds, etc.): Name of Debtor Owing You Money Amount Owed Date Expected _____________________________________________________________ $___________ _____________ _____________________________________________________________ $___________ _____________ 8. MONTHLY LIVING EXPENSES Rent/Mortgage Payment $ Vehicle Payment $ Credit Card Payment $ Vehicle Insurance $ Child Support Payment $ Transportation Costs $ Court Fines/Payments $ Doctors/Medical Costs $ Food $ Other $ Household Utilities (gas, electric, water, sewer, garbage, phone, etc.) $ 9. LIQUIDATION OF ASSETS If you are unable to sell or liquidate your assets, please use this space to explain why: _________________________ ______________________________________________________________________________________________ I hereby declare that the above statement is true to the best of my knowledge and belief. I understand that it is made for use as evidence in court and is subject to penalty for perjury. __________ __________________________________________ Date Signature of Applicant __________________________________________ Name of Applicant (printed or typed) Declaration for Waiver or Deferral of Fees Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com