Application For Deferral Or Waiver Of Fees Form. This is a Oregon form and can be use in Jackson Local County.
Tags: Application For Deferral Or Waiver Of Fees, Oregon Local County, Jackson
Jackson County Circuit Court, 100 S. Oakdale, Medford, OR 97501 541-776-7171 Instructions for Fee Deferral or Waiver Applications and Declarations If you want to apply for a deferral or waiver of fees, you must complete the attached forms (Application and Declaration of Assets). ALL SPACES on the Application and Declaration must be complete. If you are receiving public assistance, proof MUST be attached to your Declaration of Assets. We will not make copies of the proof provided so if you wish to keep a copy for your records, please make a photocopy before submitting your documents to court. Acceptable proof includes one of the following: • Food Stamps – computer printout of “issuance history” stamped by DHS, your Oregon Trail card is not acceptable proof. • TANF – computer printout of “issuance history” stamped by DHS. • Oregon Health Plan (Standard, Plus, or w/Limited Drug) – current print out of the Medical Card obtained from DHS. • Supplemental Security & Disability Income – a Benefit Verification Letter from Social Security Administration that includes ALL of the following: 1. Type of claim (supplemental, disability, etc.) 2. Date benefits began 3. Monthly benefit amount 4. Stamp and initials of Social Security Administration Staff. Proof may be obtained at the offices below: DHS Medford 800 Cardley Ave. Medford, OR 97504 541-776-6172 DHS Ashland 1658 Ashland St. Ashland, OR 97520 541-482-2041 DHS White City 3131 Avenue C White City, OR 97503 541-864-8700 Social Security 3501 Excel Dr. # 101 Medford, OR 97504 866-931-7943 APPLICATIONS THAT ARE INCOMPLETE OR MISSING THE REQUIRED PROOF STATED ABOVE WILL RESULT IN A DENIAL OF THE FEE DEFERRAL OR WAIVER. Public Flyer Fee Waiver Instructions Page 1 of 1 9/23/11 American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR JACKSON COUNTY _________________________________ Case No. _________________ Petitioner/Plaintiff vs. __________________________________ Petitioner/Plaintiff Respondent/Defendant APPLICATION FOR DEFERRAL OR WAIVER OF FEES Respondent/Defendant I am asking for deferral or waiver 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 may be required to provide documentation verifying this information. I understand that failure to do so could result in my request being denied. You must complete the attached Declaration for Deferral or Waiver 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. 1. I am applying for deferral or waiver of the following fees (check ALL that apply): Filing Fee Hearing/Non-Jury Trial Fee Arbitration Fee Sheriff’s Service Fee Parenting Class Visitors’ Fee Note: Guardianship, conservatorship and probate fees are limited to waiver or full payment; Guardianship and conservatorship cases are based on “Protected” person’s information; Probate cases are based on “Deceased” person’s information. 2. I declare that (check one of the boxes below): I am receiving assistance from the following program (check ALL that apply): Food Stamps (SNAP) Oregon Health Plan Standard Oregon Health Plan Plus Oregon Health Plan with Limited Drug Supplemental Security & Disability Income Temporary Assistance to Needy Families (TANF) Note: If you checked the above box, you must show proof that you are receiving assistance from the program. Even though I am NOT receiving assistance from any of the above programs, I am still unable to pay the fees. Supporting Documentation Verified on ___/___/20___ ___ No Proof Provided By ___________________ Public Civil Fee Deferral Waiver Application Page 1 of 2 08/01/11 OJIN code: AE American LegalNet, Inc. www.FormsWorkFlow.com 3. If the court defers fees, I understand that: 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. 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. d. The above deferral or waiver pertains only to filing, hearing, non-jury trial, parenting class, visitor, arbitration, and Sheriff’s service fees; you are still responsible for paying jury trial fees. 4. I understand that if the clerk denies my application, I have the right to ask a judge to review my application. ____ /____ /20___ Date ________________________________________ Signature of Applicant ________________________________________ Name of Applicant (printed or typed) ________________________________________ Address ________________________________________ City, State, Zip (___ )___________________________________ Telephone Number Public Civil Fee Deferral Waiver Application Page 2 of 2 08/01/11 OJIN code: AE American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR JACKSON COUNTY _________________________________ Case No. _________________ Petitioner/Plaintiff vs. __________________________________ Respondent/Defendant Petitioner/Plaintiff Respondent/Defendant DECLARATION FOR DEFERRAL OR WAIVER OF FEES (TO BE COMPLETED BY APPLICANT IN ITS ENTIRETY INCLUDING “N/A” or “0” WHEN APPROPRIATE– INCOMPLETE FORMS COULD CAUSE DENIAL OF YOUR REQUEST FOR FEE WAIVER OR DEFERRAL) ACCESS TO THIS DOCUMENT IS RESTRICTED PURSUANT TO THE COURT’S POLICY TO PROTECT THE PERSONAL PRIVACY INTERESTS OF PARTIES 1. PERSONAL Please check if EMERGENCY consideration is needed for this filing Full Name of Applicant _______________________________________________________________ FIRST NAME MIDDLE NAME LAST NAME Residence Address ___________________________________________________________________ STREET ADDRESS CITY STATE ZIP Mailing Address (if different) ___________________________________________________________ STREET ADDRESS CITY STATE ZIP Telephone#_____________ *SSN _____________ ODL/ID __________ Birthdate __________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. Are you a dependant on anyone else’s tax return? Yes No Names and ages of legal dependants living in household: If you list dependants, please outline their relationship in your household (children, parents, not related) Name / Relationship Age Name / Relationship ______________________________ ______ __________________________________ ______ ______________________________ ______ __________________________________ ______ 2. Age EMPLOYMENT AND INCOME - Your 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 ____________ Job Title__________ Length of Employment _____ Hourly Wage $ ______ Hours per Week _________ Monthly Income: Gross $________ Net (after taxes and if applicable, before Child/Spousal support deduction) $__________ If you indicated that you are unemployed, please explain the status of any unemployment claim. Household Member Employment and Income (Spouse or Domestic Partner who resides with the applicant in a common dwelling and shares living expenses) Currently Employed Not Currently Employed How long since last employment? ________ Employer Name (use previous employer if not currently employed) ____________________________________ Employer Address _____________________________________________ Work Phone ____________ Job Title__________ Length of Employment _____ Hourly Wage $ ______ Hours per Week _________ Monthly Income: Gross $________ Net (after taxes and if applicable, before Child/Spousal support deduction) $__________ If you are unable to complete the Household Member’s Employment and Income, please explain why. This information may be necessary for action on your request. Public Civil Fee Deferral Waiver Declaration Page 1 of 3 08/01/11 OJIN Code: STAS American LegalNet, Inc. www.FormsWorkFlow.com Any other income for you or household member (for example: child or spousal support, pension, retirement, unemployment, workers’ compensation, disability, tribal benefits, etc.) Source of Income (Please describe) Amount after any deduction(s) Gross amount before any deduction(s) How often received? How long received? (monthly, weekly, etc) (# weeks, months, years) (Child/Spousal support ) Child & Spousal Support $ $ Social Security $ $ $ $ Workers’ Compensation or Disability $ $ Other (please describe) $ $ $ $ (Pension/Retirement) Unemployment 3. MONTHLY LIVING EXPENSES (Amount you and spouse/partner pay out on a monthly basis) Rent/Mortgage $ Gas Heat $ *Medical $ Cable TV $ Credit Card $ Electric $ *Dental Plan $ Vehicle Payment $ Court Fines $ Water $ Phone $ Vehicle Insurance $ *Child/Spousal Support $ Sewer $ Cell Phone $ Transportation Costs $ Food $ (gas, bus pass, taxi, etc) Trash $ Internet $ Other (Child Care, etc) *Is your Child or Spousal Support Payment deducted from your paycheck/income? *Is your Medical or Dental Plan deducted from your paycheck? Medical only Yes $ No Dental only Neither If you listed no income, please explain how you are paying your living expenses. If you did not list any living expenses, please explain why. Any other individuals who help pay your living expenses: Name / Relationship Amount Frequency Payment for what (describe)? $ $ 4. MONEY ON HAND and IN BANK Cash (Pocket, Purse, Wallet, Home) (Applicants or Household Member) $ Checking Account Number Bank/Credit Union Balance $ Savings Account Number Bank/Credit Union Balance $ Other Account Number Institution Balance $ 5. MOTOR VEHICLES Year, Make, and Model (Registered to applicant or Household Member) Value Public Civil Fee Deferral Waiver Declaration Amount Owing Page 2 of 3 Payments made to: 08/01/11 OJIN Code: STAS American LegalNet, Inc. www.FormsWorkFlow.com 6. REAL ESTATE (Buying/Owned by Applicant or Household Member) Address (include city and state) Year Purchase Value / Amount Purchased Price Assessor Owing $ $ $ $ $ $ 7. Payments made to: ALL OTHER PROPERTY OR ASSETS (example: ATVs, RVs, boats, guns, jewelry, livestock, etc.): Description Value Description Value $ $ $ $ 8. $ $ MONEY OWED TO YOU BY OTHERS (example: tax refunds, judgments, trust funds, settlements, etc.): Name of Debtor Owing you Money Amount Owed Date Expected $ $ 9. LIQUIDATION OF ASSETS If you are unable to sell or liquidate your assets, please use this space to explain why: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 10. OTHER INFORMATION YOU WANT COURT TO CONSIDER Example: This is a Domestic Relations case, your spouse controls all family resources, and you have no money __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Have you retained an attorney, or do you plan to do so to represent you in this matter? _________________________ If so, who is your attorney? ________________________________________________________________________ Have you paid your attorney money? Yes No Is there a contingency fee agreement? Yes No If so, how much? $__________ ____ Initials I acknowledge that it is my responsibility to call the court and verify the status of this application. Pleadings are not considered filed until: 1) your fee waiver is approved; 2) you have agreed to a deferred payment imposition; 3) your request has been denied and you have paid the appropriate filing fee. I HEREBY SWEAR 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 / Proposed Guardian / Personal Representative ________________________________________________ Printed Name of Applicant / Proposed Guardian / Personal Representative Public Civil Fee Deferral Waiver Declaration Page 3 of 3 08/01/11 OJIN Code: STAS American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR JACKSON COUNTY ______________________________________ Petitioner/Plaintiff vs. ______________________________________ Respondent/Defendant Case No. _________________ Petitioner/Plaintiff Respondent/Defendant ORDER REGARDING DEFERRAL OR WAIVER OF FEES CLERK’S ORDER I have reviewed (Applicant’s name) _____________________________________’s application for waiver or deferral of fees and ORDER the following: Deferral 1. The following fees are DEFERRED Filing Fee Hearing/Non-Jury Trial Fee Arbitration Fee Sheriff’s Service Fee Parenting Class Visitors’ Fee Waiver 2. The following fees are WAIVED Filing Fee Hearing/Non-Jury Trial Fee Arbitration Fee Sheriff’s Service Fee Parenting Class Visitors’ Fee Denial 3. The applicant’s request for deferral or waiver of fees is DENIED because: Applicant is financially able to pay the fees (see part ___ of the Declaration); Incomplete Application / Declaration (see part ___ of the Declaration); Applicant does not qualify under the General Order regarding deferral and waiver of fees; Other findings ___________________________________________________________. Full payment of court fees and assessments are deferred until a Judgment is executed. If full payment of court fees and assessments does not occur at time of entry of the Judgment, a Supplemental Judgment for any unpaid fees and assessments shall be executed and a payment plan created. The above Deferral or Waiver pertains only to the above fee(s); you are still responsible for paying jury trial fees. Financial Code: Amount $___________ Financial Code: Amount $____________ Dated: ________________20____. ______________________________________ Circuit Court Clerk Public Civil Fee Deferral Waiver Order Page 1 of 1 08/01/11 OJIN Code: ORFW (Order Fee Waiver), ORFD (Order Fee Deferral), or ORDN (Order of Denial) American LegalNet, Inc. www.FormsWorkFlow.com